Provider First Line Business Practice Location Address:
4343 N KEDZIE 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:
60618-1301
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
773-604-4419
Provider Business Practice Location Address Fax Number:
773-604-5235
Provider Enumeration Date:
08/01/2006