Provider First Line Business Practice Location Address:
1516 LAFAYETTE AVE
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:
47804-1336
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
812-466-3555
Provider Business Practice Location Address Fax Number:
812-466-4754
Provider Enumeration Date:
08/11/2006