Provider First Line Business Practice Location Address:
1901 W HARRISON ST
Provider Second Line Business Practice Location Address:
ORTHO OFFICE ROOM 657
Provider Business Practice Location Address City Name:
CHICAGO
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60612-3714
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
312-864-5365
Provider Business Practice Location Address Fax Number:
312-864-9755
Provider Enumeration Date:
08/03/2006