Provider First Line Business Practice Location Address:
1800 S 3RD 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:
47802-1920
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
812-232-4036
Provider Business Practice Location Address Fax Number:
812-235-0420
Provider Enumeration Date:
12/09/2005