Provider First Line Business Practice Location Address:
89 CHERRY 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:
47807-2942
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
812-232-4112
Provider Business Practice Location Address Fax Number:
812-232-3052
Provider Enumeration Date:
11/03/2006