Provider First Line Business Practice Location Address:
129 N 8TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
EAST ST LOUIS
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
62201
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
618-482-7242
Provider Business Practice Location Address Fax Number:
314-810-1399
Provider Enumeration Date:
06/13/2005