Provider First Line Business Practice Location Address:
7TH STREET
Provider Second Line Business Practice Location Address:
INDIANA STATE UNIVERSITY, ARENA BUILDING
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
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
812-249-9468
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/14/2006