Provider First Line Business Practice Location Address: 
400 LAKE COOK RD
    Provider Second Line Business Practice Location Address: 
SUITE 200A
    Provider Business Practice Location Address City Name: 
DEERFIELD
    Provider Business Practice Location Address State Name: 
IL
    Provider Business Practice Location Address Postal Code: 
60015
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
847-945-8565
    Provider Business Practice Location Address Fax Number: 
847-945-8278
    Provider Enumeration Date: 
01/17/2007