Provider First Line Business Practice Location Address:
1429 NO. 6TH 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:
47807-1037
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
812-238-4402
Provider Business Practice Location Address Fax Number:
812-238-4466
Provider Enumeration Date:
05/17/2011