Provider First Line Business Practice Location Address:
1625 N 4TH 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:
47804-4067
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
812-232-8716
Provider Business Practice Location Address Fax Number:
812-232-7768
Provider Enumeration Date:
05/04/2006