Provider First Line Business Practice Location Address:
2525 N LINCOLN AVE
Provider Second Line Business Practice Location Address:
SUITE D-1
Provider Business Practice Location Address City Name:
CHICAGO
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60614-2313
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
773-549-1516
Provider Business Practice Location Address Fax Number:
773-549-8928
Provider Enumeration Date:
09/27/2005