Provider First Line Business Practice Location Address:
1969 W OGDEN AVE
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:
60612-3765
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
312-864-7213
Provider Business Practice Location Address Fax Number:
312-864-9624
Provider Enumeration Date:
06/16/2005