Provider First Line Business Practice Location Address:
1111 WEST NORTH 12TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SHELBYVILLE
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
62565-9554
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
217-774-2111
Provider Business Practice Location Address Fax Number:
217-774-2209
Provider Enumeration Date:
09/21/2005