Provider First Line Business Practice Location Address:
1201 S PRAIRIE AVE APT 2102
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:
60605-3425
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
773-882-5263
Provider Business Practice Location Address Fax Number:
312-929-2991
Provider Enumeration Date:
09/21/2006