Provider First Line Business Practice Location Address:
CAMPUS BOX 1066
Provider Second Line Business Practice Location Address:
SOUTHERN ILLINOIS UNIVERSITY EDWARDSVILLE
Provider Business Practice Location Address City Name:
EDWARDSVILLE
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
62026-1066
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
618-650-3908
Provider Business Practice Location Address Fax Number:
618-650-2522
Provider Enumeration Date:
08/24/2009