Provider First Line Business Practice Location Address:
1601 N HARLEM 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:
60707-4303
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
773-836-4110
Provider Business Practice Location Address Fax Number:
773-637-1109
Provider Enumeration Date:
06/29/2011