Provider First Line Business Practice Location Address:
2240 W OGDEN AVE STE 3
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:
60612-4882
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
773-537-3250
Provider Business Practice Location Address Fax Number:
773-432-6547
Provider Enumeration Date:
08/12/2025