Provider First Line Business Practice Location Address:
800 E CARPENTER STREET
Provider Second Line Business Practice Location Address:
BOX 43
Provider Business Practice Location Address City Name:
SPRINGFIELD
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
62769-1000
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
217-814-5178
Provider Business Practice Location Address Fax Number:
217-757-6458
Provider Enumeration Date:
06/17/2025