Provider First Line Business Practice Location Address:
4651 N LAFAYETTE 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:
47805-1832
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
812-246-6911
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/27/2007