Provider First Line Business Practice Location Address: 
1817 S LOOMIS ST
    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: 
60608-3018
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
312-666-6511
    Provider Business Practice Location Address Fax Number: 
312-666-1658
    Provider Enumeration Date: 
08/10/2009