Provider First Line Business Practice Location Address:
1747 W ROOSEVELT RD
Provider Second Line Business Practice Location Address:
M-C 747
Provider Business Practice Location Address City Name:
CHICAGO
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60608-1264
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
312-996-6219
Provider Business Practice Location Address Fax Number:
312-996-9534
Provider Enumeration Date:
06/19/2007