Provider First Line Business Practice Location Address:
202 W PARK AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CHAMPAIGN
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
61820-3929
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
217-373-2436
Provider Business Practice Location Address Fax Number:
217-373-2444
Provider Enumeration Date:
12/20/2006