Provider First Line Business Practice Location Address:
2106 N HUMBOLDT BLVD APT 3
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CHICAGO
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60647-3865
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
570-926-3092
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/23/2025