Provider First Line Business Practice Location Address:
1401 S STATE ST STE B
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CHAMPAIGN
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
61820-6877
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
217-351-2021
Provider Business Practice Location Address Fax Number:
217-351-1740
Provider Enumeration Date:
12/06/2006