Provider First Line Business Practice Location Address:
10 S KEDZIE AVE
Provider Second Line Business Practice Location Address:
ROOM 206
Provider Business Practice Location Address City Name:
CHICAGO
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60612-2706
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
312-746-6833
Provider Business Practice Location Address Fax Number:
312-746-9049
Provider Enumeration Date:
10/20/2006