Provider First Line Business Practice Location Address:
3903 S 7TH ST
Provider Second Line Business Practice Location Address:
SUITE 2B
Provider Business Practice Location Address City Name:
TERRE HAUTE
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
47802-5710
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
812-232-2708
Provider Business Practice Location Address Fax Number:
812-235-0687
Provider Enumeration Date:
09/06/2005