Provider First Line Business Practice Location Address:
3903 S 7TH ST
Provider Second Line Business Practice Location Address:
SUITE 1D
Provider Business Practice Location Address City Name:
TERRE HAUTE
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
47802-5710
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
812-234-0787
Provider Business Practice Location Address Fax Number:
812-232-3253
Provider Enumeration Date:
10/03/2006