Provider First Line Business Practice Location Address:
2349 S WENTWORTH AVE STE A
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:
60616-0110
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
312-808-1893
Provider Business Practice Location Address Fax Number:
312-808-1834
Provider Enumeration Date:
10/07/2025