Provider First Line Business Practice Location Address:
1080 E. PARK STREET
Provider Second Line Business Practice Location Address:
1ST FLOOR, NORTH
Provider Business Practice Location Address City Name:
CARBONDALE
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
62901
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
618-529-1151
Provider Business Practice Location Address Fax Number:
618-549-9540
Provider Enumeration Date:
04/27/2011