Provider First Line Business Practice Location Address:
1711 N 6 1/2 ST
Provider Second Line Business Practice Location Address:
STE 200
Provider Business Practice Location Address City Name:
TERRE HAUTE
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
47804-2766
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
812-232-0564
Provider Business Practice Location Address Fax Number:
812-242-3848
Provider Enumeration Date:
01/09/2008