Provider First Line Business Practice Location Address:
1200 UNIVERSITY AVE.
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CARLINVILLE
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
62626-9600
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
217-854-4433
Provider Business Practice Location Address Fax Number:
217-854-6291
Provider Enumeration Date:
10/31/2005