Provider First Line Business Practice Location Address:
1620 W HARRISON ST
Provider Second Line Business Practice Location Address:
SUITE 7 KELLOGG
Provider Business Practice Location Address City Name:
CHICAGO
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60612-3801
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
312-942-5046
Provider Business Practice Location Address Fax Number:
312-942-2243
Provider Enumeration Date:
12/19/2006