Provider First Line Business Practice Location Address:
1220 S 19TH 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:
47803-4011
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
812-238-9871
Provider Business Practice Location Address Fax Number:
812-244-0306
Provider Enumeration Date:
08/05/2006