Provider First Line Business Practice Location Address:
1361 POPLAR 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:
47807-4580
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
812-249-9750
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/27/2010