Provider First Line Business Practice Location Address:
214 S UNIVERSITY AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CARBONDALE
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
62901-2925
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
618-351-0743
Provider Business Practice Location Address Fax Number:
618-351-0945
Provider Enumeration Date:
12/14/2009