Provider First Line Business Practice Location Address:
1513 N 6TH 1/2 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:
47807-1039
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
812-238-7631
Provider Business Practice Location Address Fax Number:
812-238-7003
Provider Enumeration Date:
06/16/2011