Provider First Line Business Practice Location Address:
111 SOUTH 20TH
Provider Second Line Business Practice Location Address:
KIDS HOPE UNITED
Provider Business Practice Location Address City Name:
MOUNT VERNON
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
62864
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
618-204-1986
Provider Business Practice Location Address Fax Number:
618-242-1150
Provider Enumeration Date:
11/17/2006