Provider First Line Business Practice Location Address:
1450 E MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CARBONDALE
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
62901-3140
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
618-457-6440
Provider Business Practice Location Address Fax Number:
618-549-2232
Provider Enumeration Date:
10/03/2006