Provider First Line Business Practice Location Address:
5500 S US HIGHWAY 41
Provider Second Line Business Practice Location Address:
SUITE 110
Provider Business Practice Location Address City Name:
TERRE HAUTE
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
47802-4745
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
812-299-1723
Provider Business Practice Location Address Fax Number:
812-299-4862
Provider Enumeration Date:
11/22/2006