Provider First Line Business Practice Location Address:
1800 E LAKE SHORE DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DECATUR
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
62521-3810
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
217-464-2729
Provider Business Practice Location Address Fax Number:
217-464-1693
Provider Enumeration Date:
07/05/2005