Provider First Line Business Practice Location Address:
1601 S HALSTED ST
Provider Second Line Business Practice Location Address:
UNIT 602
Provider Business Practice Location Address City Name:
CHICAGO
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60608-2327
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
312-421-7223
Provider Business Practice Location Address Fax Number:
312-421-7223
Provider Enumeration Date:
09/27/2006