Provider First Line Business Practice Location Address:
3815 HARRISON AVE
Provider Second Line Business Practice Location Address:
DETOX A2 - 2ND FLOOR NORTHWEST A2
Provider Business Practice Location Address City Name:
ROCKFORD
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
61108-7631
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
815-391-1000
Provider Business Practice Location Address Fax Number:
815-391-5040
Provider Enumeration Date:
11/14/2008