Provider First Line Business Practice Location Address:
1184 W MAIN ST
Provider Second Line Business Practice Location Address:
GRISWOLD PHYSICAL EDUCATION CENTER
Provider Business Practice Location Address City Name:
DECATUR
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
62522-2039
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
845-988-6028
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/02/2015