Provider First Line Business Practice Location Address:
5969 S ERNEST 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:
47802-8111
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
812-238-4499
Provider Business Practice Location Address Fax Number:
812-238-4493
Provider Enumeration Date:
10/14/2005