Provider First Line Business Practice Location Address: 
2400 W SCHNEIDMAN DR
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
QUINCY
    Provider Business Practice Location Address State Name: 
IL
    Provider Business Practice Location Address Postal Code: 
62305-1294
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
217-214-0591
    Provider Business Practice Location Address Fax Number: 
217-214-7166
    Provider Enumeration Date: 
10/15/2009