Provider First Line Business Practice Location Address: 
109 KENWOOD RD
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
CHAMPAIGN
    Provider Business Practice Location Address State Name: 
IL
    Provider Business Practice Location Address Postal Code: 
61821-2905
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
217-356-5164
    Provider Business Practice Location Address Fax Number: 
217-356-7873
    Provider Enumeration Date: 
12/05/2016