Provider First Line Business Practice Location Address: 
425 E STATE STREET
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
JACKSONVILLE
    Provider Business Practice Location Address State Name: 
IL
    Provider Business Practice Location Address Postal Code: 
62650-2125
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
217-245-5111
    Provider Business Practice Location Address Fax Number: 
217-243-4773
    Provider Enumeration Date: 
06/26/2006