Provider First Line Business Practice Location Address:
2311 W HOWARD ST UNIT WEST
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:
60645-1503
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
773-743-0100
Provider Business Practice Location Address Fax Number:
773-743-6692
Provider Enumeration Date:
12/20/2006