Provider First Line Business Practice Location Address:
9718 S HALSTED 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:
60628-1007
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
773-238-4500
Provider Business Practice Location Address Fax Number:
773-238-4503
Provider Enumeration Date:
10/23/2012