Provider First Line Business Practice Location Address:
175 CANAL 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:
47807-2616
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
812-234-5553
Provider Business Practice Location Address Fax Number:
812-238-8313
Provider Enumeration Date:
09/16/2006