Provider First Line Business Practice Location Address: 
2528 N LINCOLN AVE
    Provider Second Line Business Practice Location Address: 
SUITE 116
    Provider Business Practice Location Address City Name: 
CHICAGO
    Provider Business Practice Location Address State Name: 
IL
    Provider Business Practice Location Address Postal Code: 
60614-2333
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
312-371-4095
    Provider Business Practice Location Address Fax Number: 
312-344-1054
    Provider Enumeration Date: 
06/30/2011