Provider First Line Business Practice Location Address:
5467 S UNIVERSITY AVE
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:
60615-5114
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
773-643-0452
Provider Business Practice Location Address Fax Number:
773-643-0620
Provider Enumeration Date:
02/16/2010