Provider First Line Business Practice Location Address:
BOX 469
Provider Second Line Business Practice Location Address:
314 W SOUTH ST
Provider Business Practice Location Address City Name:
PINCKNEYVILLE
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
62274
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
618-357-2445
Provider Business Practice Location Address Fax Number:
618-357-9549
Provider Enumeration Date:
07/31/2006