Provider First Line Business Practice Location Address:
1007 W HARRISON ST RM 1062D
Provider Second Line Business Practice Location Address:
M/C 285
Provider Business Practice Location Address City Name:
CHICAGO
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60607-7135
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
312-355-3812
Provider Business Practice Location Address Fax Number:
312-413-4122
Provider Enumeration Date:
10/31/2007