Provider First Line Business Practice Location Address:
3500 MAPLE AVE
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:
47804-1732
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
812-238-1555
Provider Business Practice Location Address Fax Number:
812-238-2514
Provider Enumeration Date:
12/29/2006