Provider First Line Business Practice Location Address:
326 S 20TH 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:
47803-2106
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
812-235-1197
Provider Business Practice Location Address Fax Number:
812-235-1197
Provider Enumeration Date:
02/19/2007