Provider First Line Business Practice Location Address: 
1725 W. HARRISON STREET
    Provider Second Line Business Practice Location Address: 
PROFESSIONAL OFFICE BUILDING SUITE 710
    Provider Business Practice Location Address City Name: 
CHICAGO
    Provider Business Practice Location Address State Name: 
IL
    Provider Business Practice Location Address Postal Code: 
60612
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
312-942-3034
    Provider Business Practice Location Address Fax Number: 
312-942-4168
    Provider Enumeration Date: 
04/29/2015