Provider First Line Business Practice Location Address:
SOUTHERN ILLINOIS UNIVERSITY -EDWARDSVILLE
Provider Second Line Business Practice Location Address:
ATHLETICS, BOX 1129
Provider Business Practice Location Address City Name:
EDWARDSVILLE
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
62026-1129
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
618-650-2160
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
12/20/2006