Provider First Line Business Practice Location Address:
1308 S 6TH 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:
47802-1112
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
812-462-3256
Provider Business Practice Location Address Fax Number:
812-234-4433
Provider Enumeration Date:
11/16/2010