Provider First Line Business Practice Location Address:
348 W PRAIRIE AVE
Provider Second Line Business Practice Location Address:
STE 3
Provider Business Practice Location Address City Name:
DECATUR
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
62522-2471
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
217-422-0053
Provider Business Practice Location Address Fax Number:
217-422-0374
Provider Enumeration Date:
08/28/2006