Provider First Line Business Practice Location Address:
407 E UNIVERSITY AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CHAMPAIGN
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
61820-3865
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
217-954-0119
Provider Business Practice Location Address Fax Number:
217-954-1698
Provider Enumeration Date:
07/28/2005