Provider First Line Business Practice Location Address:
1421 N 7TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TERRE HAUTE
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
47807-1005
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
812-232-7192
Provider Business Practice Location Address Fax Number:
903-677-5586
Provider Enumeration Date:
11/17/2005