Provider First Line Business Practice Location Address:
600 S HOUSTON ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TAYLORVILLE
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
62568-2073
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
217-824-9636
Provider Business Practice Location Address Fax Number:
217-824-8437
Provider Enumeration Date:
10/11/2005