Provider First Line Business Practice Location Address:
1635 N 3RD 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:
47804-4044
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
812-231-1040
Provider Business Practice Location Address Fax Number:
812-231-1044
Provider Enumeration Date:
11/29/2013