Provider First Line Business Practice Location Address:
1107 S. DIVISION AVE.
Provider Second Line Business Practice Location Address:
KSB CENTER FOR HEALTH SERVICES/POLO
Provider Business Practice Location Address City Name:
POLO
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
61064
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
815-946-3453
Provider Business Practice Location Address Fax Number:
815-946-3908
Provider Enumeration Date:
01/27/2006