Provider First Line Business Practice Location Address:
WEST ROUTE 16
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SHELBYVILLE
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
62565-0199
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
217-774-4422
Provider Business Practice Location Address Fax Number:
217-774-4722
Provider Enumeration Date:
10/25/2006