Provider First Line Business Practice Location Address:
2001 S OAK ST
Provider Second Line Business Practice Location Address:
SUITE B
Provider Business Practice Location Address City Name:
CHAMPAIGN
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
61820-0906
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
217-333-2205
Provider Business Practice Location Address Fax Number:
217-333-2206
Provider Enumeration Date:
02/20/2008