Provider First Line Business Practice Location Address:
1050 W DAKIN ST
Provider Second Line Business Practice Location Address:
1A
Provider Business Practice Location Address City Name:
CHICAGO
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60613-2937
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
312-391-3786
Provider Business Practice Location Address Fax Number:
773-681-7168
Provider Enumeration Date:
11/13/2008