Provider First Line Business Practice Location Address:
4414 S 7TH ST
Provider Second Line Business Practice Location Address:
STE C
Provider Business Practice Location Address City Name:
TERRA HAUTE
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
47802
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
812-299-9281
Provider Business Practice Location Address Fax Number:
812-299-2142
Provider Enumeration Date:
04/19/2006