Provider First Line Business Practice Location Address:
110 HORTON FIELDHOUSE
Provider Second Line Business Practice Location Address:
ILLINOIS STATE UNIVERSITY ATHLETIC TRAINING
Provider Business Practice Location Address City Name:
NORMAL
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
61709-2660
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
309-438-0647
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/29/2015