Provider First Line Business Practice Location Address:
3630 N. HARLEM AVENUE
Provider Second Line Business Practice Location Address:
214
Provider Business Practice Location Address City Name:
CHICAGO
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60634-3194
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
773-848-4846
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/27/2010