Provider First Line Business Practice Location Address:
1815 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:
47802-1919
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
812-232-1464
Provider Business Practice Location Address Fax Number:
812-235-0668
Provider Enumeration Date:
07/03/2006