Provider First Line Business Practice Location Address:
1653 W HARRISON ST
Provider Second Line Business Practice Location Address:
JONES BLDG 412 ACUTE PT
Provider Business Practice Location Address City Name:
CHICAGO
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60612-3824
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
312-942-5847
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/17/2007