Provider First Line Business Practice Location Address:
1421 N 7TH 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:
47807-1005
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
812-231-4608
Provider Business Practice Location Address Fax Number:
812-231-4675
Provider Enumeration Date:
06/26/2006