Provider First Line Business Practice Location Address:
3736 S 4TH 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:
47802-5507
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
812-237-1411
Provider Business Practice Location Address Fax Number:
812-237-9242
Provider Enumeration Date:
07/01/2021