Provider First Line Business Practice Location Address:
374 E. GRAND AVE,
Provider Second Line Business Practice Location Address:
BLDG 269, ROOM 140A C/O STUDENT HEALTH CTR.
Provider Business Practice Location Address City Name:
CARBONDALE
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
62901-3962
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
618-549-0615
Provider Business Practice Location Address Fax Number:
618-457-0157
Provider Enumeration Date:
11/16/2005