Provider First Line Business Practice Location Address:
1503 OHIO STREET
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:
47807-4009
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
812-232-4252
Provider Business Practice Location Address Fax Number:
812-238-9143
Provider Enumeration Date:
04/22/2006