Provider First Line Business Practice Location Address:
4157 N KENMORE AVE
Provider Second Line Business Practice Location Address:
#3S
Provider Business Practice Location Address City Name:
CHICAGO
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60613-6417
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
773-697-3448
Provider Business Practice Location Address Fax Number:
773-634-8468
Provider Enumeration Date:
02/15/2012