Provider First Line Business Practice Location Address:
315 W CARPENTER ST
Provider Second Line Business Practice Location Address:
2ND FLOOR
Provider Business Practice Location Address City Name:
SPRINGFIELD
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
62702-4901
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
217-545-1025
Provider Business Practice Location Address Fax Number:
217-545-0952
Provider Enumeration Date:
10/04/2005