Provider First Line Business Practice Location Address:
1900 W. POLK STREET
Provider Second Line Business Practice Location Address:
ADMINISTRATION BLDG. - ROOM 154
Provider Business Practice Location Address City Name:
CHICAGO
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60612
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
312-835-5765
Provider Business Practice Location Address Fax Number:
312-864-9009
Provider Enumeration Date:
10/16/2018