Provider First Line Business Practice Location Address:
1460 N HALSTED
Provider Second Line Business Practice Location Address:
SUITE 503
Provider Business Practice Location Address City Name:
CHICAGO
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60642-2613
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
773-472-1444
Provider Business Practice Location Address Fax Number:
773-472-4424
Provider Enumeration Date:
06/25/2006