Provider First Line Business Practice Location Address:
3430 S 4TH 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:
47802-4168
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
812-234-2644
Provider Business Practice Location Address Fax Number:
812-234-2645
Provider Enumeration Date:
04/17/2007