Provider First Line Business Practice Location Address:
1024 LAFAYETTE AVE
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:
47804-2932
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
812-232-6654
Provider Business Practice Location Address Fax Number:
812-232-4255
Provider Enumeration Date:
06/05/2006