Provider First Line Business Practice Location Address:
2800 S VERNON
Provider Second Line Business Practice Location Address:
1ST FLOOR FLORSHEIM MEDICAL BLDG
Provider Business Practice Location Address City Name:
CHICAGO
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60616
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
312-842-1900
Provider Business Practice Location Address Fax Number:
312-842-4387
Provider Enumeration Date:
07/28/2006