Provider First Line Business Practice Location Address: 
4200 W PETERSON AVE
    Provider Second Line Business Practice Location Address: 
SUITE 117
    Provider Business Practice Location Address City Name: 
CHICAGO
    Provider Business Practice Location Address State Name: 
IL
    Provider Business Practice Location Address Postal Code: 
60646
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
773-777-7780
    Provider Business Practice Location Address Fax Number: 
847-564-2564
    Provider Enumeration Date: 
12/08/2006