Provider First Line Business Practice Location Address:
5418 N KEDZIE AVE
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:
60625-3922
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
773-279-8078
Provider Business Practice Location Address Fax Number:
773-279-8079
Provider Enumeration Date:
11/01/2010