Provider First Line Business Practice Location Address:
2321 N 10TH 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:
47804-2310
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
812-238-7384
Provider Business Practice Location Address Fax Number:
812-238-7002
Provider Enumeration Date:
01/11/2006