Provider First Line Business Practice Location Address:
13 NORTH WALNUT STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PINCKNEYVILLE
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
62274
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
618-357-2147
Provider Business Practice Location Address Fax Number:
618-357-8142
Provider Enumeration Date:
11/06/2006