Provider First Line Business Practice Location Address:
1601 LAFAYETTE AVE
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:
61938-5280
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
217-234-3648
Provider Business Practice Location Address Fax Number:
217-235-0356
Provider Enumeration Date:
06/23/2005