Provider First Line Business Practice Location Address:
1653 W CONGRESS PKWY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CHICAGO
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60612-3833
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
312-942-5495
Provider Business Practice Location Address Fax Number:
312-942-5727
Provider Enumeration Date:
12/07/2010