Provider First Line Business Practice Location Address:
213 W CLAY ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ROODHOUSE
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
62082-1344
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
217-589-4313
Provider Business Practice Location Address Fax Number:
217-589-5121
Provider Enumeration Date:
10/17/2006