Provider First Line Business Practice Location Address:
1616 LAFAYETTE AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MATTOON
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
61938-3926
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
217-234-2243
Provider Business Practice Location Address Fax Number:
217-234-2253
Provider Enumeration Date:
10/18/2006