Provider First Line Business Practice Location Address:
1725 N 5TH 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:
47804-4010
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
812-242-3005
Provider Business Practice Location Address Fax Number:
812-242-3054
Provider Enumeration Date:
08/10/2007