Provider First Line Business Practice Location Address:
5500 S US HIGHWAY 41
Provider Second Line Business Practice Location Address:
SUITE 1
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:
812-238-7791
Provider Business Practice Location Address Fax Number:
812-238-7790
Provider Enumeration Date:
11/02/2005