Provider First Line Business Practice Location Address:
5679 N COUNTY ROAD 1020E
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MATTOON
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
61938-8529
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
800-548-5898
Provider Business Practice Location Address Fax Number:
217-234-7013
Provider Enumeration Date:
07/01/2026