Provider First Line Business Practice Location Address:
1231 S DAMEN 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:
60608-1145
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
312-243-3741
Provider Business Practice Location Address Fax Number:
312-243-0754
Provider Enumeration Date:
06/19/2009