Provider First Line Business Practice Location Address: 
285 SOUTH FARNHAM STREET
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
GALESBURG
    Provider Business Practice Location Address State Name: 
IL
    Provider Business Practice Location Address Postal Code: 
61401-5323
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
309-343-1550
    Provider Business Practice Location Address Fax Number: 
309-343-6318
    Provider Enumeration Date: 
03/26/2008