Provider First Line Business Practice Location Address:
12251 S HALSTED ST
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:
60628-6427
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
773-928-6777
Provider Business Practice Location Address Fax Number:
773-928-1280
Provider Enumeration Date:
06/09/2006