Provider First Line Business Practice Location Address:
567 N 5TH ST
Provider Second Line Business Practice Location Address:
SS172
Provider Business Practice Location Address City Name:
TERRE HAUTE
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
47809-1903
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
812-237-9613
Provider Business Practice Location Address Fax Number:
812-237-9612
Provider Enumeration Date:
01/09/2012