Provider First Line Business Practice Location Address:
1647 N HUMBOLDT BLVD
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:
60647-5015
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
773-216-6144
Provider Business Practice Location Address Fax Number:
773-486-5814
Provider Enumeration Date:
08/20/2007