Provider First Line Business Practice Location Address:
247 W PRAIRIE AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DECATUR
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
62523-1220
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
217-428-3458
Provider Business Practice Location Address Fax Number:
217-935-4508
Provider Enumeration Date:
01/30/2007