Provider First Line Business Practice Location Address:
2158-B S ARCHER AVE
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:
60616-1514
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
312-225-2222
Provider Business Practice Location Address Fax Number:
312-225-2219
Provider Enumeration Date:
11/16/2005