Provider First Line Business Practice Location Address:
5548 S KENWOOD AVE
Provider Second Line Business Practice Location Address:
REAR COACH HOUSE
Provider Business Practice Location Address City Name:
CHICAGO
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60637-1714
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
773-684-8250
Provider Business Practice Location Address Fax Number:
773-943-6368
Provider Enumeration Date:
06/12/2006