Provider First Line Business Practice Location Address:
1050 W KINZIE 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:
60642-6537
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
312-850-0201
Provider Business Practice Location Address Fax Number:
312-850-9209
Provider Enumeration Date:
10/12/2006