Provider First Line Business Practice Location Address:
2100 N 12TH 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:
47804-2325
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
812-200-0441
Provider Business Practice Location Address Fax Number:
812-610-2857
Provider Enumeration Date:
06/29/2011