Provider First Line Business Practice Location Address:
2723 S 7TH ST STE L
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:
47802-3558
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
812-917-4629
Provider Business Practice Location Address Fax Number:
812-917-4631
Provider Enumeration Date:
01/06/2006