Provider First Line Business Practice Location Address:
3213-21 WEST 47TH PLACE
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:
60632-3011
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
773-254-6044
Provider Business Practice Location Address Fax Number:
773-254-6115
Provider Enumeration Date:
06/15/2009