Provider First Line Business Practice Location Address: 
2160 S 1ST AVE
    Provider Second Line Business Practice Location Address: 
(9608 ROBERTS RD., HICKORY HILLS, IL. 60457)
    Provider Business Practice Location Address City Name: 
MAYWOOD
    Provider Business Practice Location Address State Name: 
IL
    Provider Business Practice Location Address Postal Code: 
60153-3328
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
708-233-5333
    Provider Business Practice Location Address Fax Number: 
708-233-5348
    Provider Enumeration Date: 
12/30/2005