Provider First Line Business Practice Location Address:
4350 S US HIGHWAY 41
Provider Second Line Business Practice Location Address:
SAM'S CLUB
Provider Business Practice Location Address City Name:
TERRE HAUTE
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
47802-4407
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
812-238-5532
Provider Business Practice Location Address Fax Number:
812-238-5681
Provider Enumeration Date:
12/29/2006