Provider First Line Business Practice Location Address:
4639 W WASHINGTON ST
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:
60644
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
773-287-9002
Provider Business Practice Location Address Fax Number:
773-287-9188
Provider Enumeration Date:
10/02/2006