Provider First Line Business Practice Location Address:
2800 COLLEGE AVENUE SOUTHERN IL UNIVERSITY SCHOOL OF DE
Provider Second Line Business Practice Location Address:
BUILDING 285
Provider Business Practice Location Address City Name:
ALTON
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
62002
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
612-474-7024
Provider Business Practice Location Address Fax Number:
618-474-7249
Provider Enumeration Date:
05/08/2019