Provider First Line Business Practice Location Address: 
924 W AINSLIE ST
    Provider Second Line Business Practice Location Address: 
APT 1N
    Provider Business Practice Location Address City Name: 
CHICAGO
    Provider Business Practice Location Address State Name: 
IL
    Provider Business Practice Location Address Postal Code: 
60640-3813
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
708-822-8917
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
12/18/2015