Provider First Line Business Practice Location Address:
1102 W PRATT BLVD
Provider Second Line Business Practice Location Address:
APT 3E
Provider Business Practice Location Address City Name:
CHICAGO
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60626-4453
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
773-764-4967
Provider Business Practice Location Address Fax Number:
773-764-4967
Provider Enumeration Date:
09/30/2005