Provider First Line Business Practice Location Address: 
3387 S US HIGHWAY 41
    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: 
47802-4188
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
812-232-5532
    Provider Business Practice Location Address Fax Number: 
812-232-2574
    Provider Enumeration Date: 
12/04/2016