Provider First Line Business Practice Location Address:
3903 S 7TH ST
Provider Second Line Business Practice Location Address:
STE 2E
Provider Business Practice Location Address City Name:
TERRE HAUTE
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
47802-5710
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
812-235-7370
Provider Business Practice Location Address Fax Number:
812-235-7570
Provider Enumeration Date:
10/27/2005