Provider First Line Business Practice Location Address: 
1260 E 2200 NORTH RD
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
MANSFIELD
    Provider Business Practice Location Address State Name: 
IL
    Provider Business Practice Location Address Postal Code: 
61854-6883
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
217-762-7609
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
04/14/2008