Provider First Line Business Practice Location Address:
422 POPLAR STREET
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:
47807-4209
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
812-242-3700
Provider Business Practice Location Address Fax Number:
812-234-3565
Provider Enumeration Date:
05/24/2007