Provider First Line Business Practice Location Address: 
8001 N MILWAUKEE AVE
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
NILES
    Provider Business Practice Location Address State Name: 
IL
    Provider Business Practice Location Address Postal Code: 
60714-2801
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
847-583-0409
    Provider Business Practice Location Address Fax Number: 
847-583-0449
    Provider Enumeration Date: 
09/06/2011