Provider First Line Business Practice Location Address: 
422 W MELROSE ST
    Provider Second Line Business Practice Location Address: 
APT. 605
    Provider Business Practice Location Address City Name: 
CHICAGO
    Provider Business Practice Location Address State Name: 
IL
    Provider Business Practice Location Address Postal Code: 
60657-3849
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
708-363-6721
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
08/07/2009