Provider First Line Business Practice Location Address: 
962 HARVARD TER
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
EVANSTON
    Provider Business Practice Location Address State Name: 
IL
    Provider Business Practice Location Address Postal Code: 
60202-6425
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
773-577-9273
    Provider Business Practice Location Address Fax Number: 
773-248-9206
    Provider Enumeration Date: 
04/02/2007