Provider First Line Business Practice Location Address: 
1220 S PARK AVE
    Provider Second Line Business Practice Location Address: 
SUITE D
    Provider Business Practice Location Address City Name: 
HERRIN
    Provider Business Practice Location Address State Name: 
IL
    Provider Business Practice Location Address Postal Code: 
62948-4177
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
618-988-1757
    Provider Business Practice Location Address Fax Number: 
618-988-1700
    Provider Enumeration Date: 
02/27/2006