Provider First Line Business Practice Location Address:
221 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:
47807-4129
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
812-232-0064
Provider Business Practice Location Address Fax Number:
812-232-3834
Provider Enumeration Date:
06/28/2006