Provider First Line Business Practice Location Address:
1460 N HALSTED ST
Provider Second Line Business Practice Location Address:
SUITE #505
Provider Business Practice Location Address City Name:
CHICAGO
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60642-2605
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
312-266-6462
Provider Business Practice Location Address Fax Number:
312-266-6481
Provider Enumeration Date:
01/12/2007