Provider First Line Business Practice Location Address:
6202 S HALSTED ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CHICAGO
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60621-2029
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
773-874-6608
Provider Business Practice Location Address Fax Number:
773-874-6609
Provider Enumeration Date:
09/20/2005