Provider First Line Business Practice Location Address: 
405 N MACARTHUR BLVD
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
SPRINGFIELD
    Provider Business Practice Location Address State Name: 
IL
    Provider Business Practice Location Address Postal Code: 
62702-2312
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
217-698-0200
    Provider Business Practice Location Address Fax Number: 
217-698-8839
    Provider Enumeration Date: 
09/10/2009