Provider First Line Business Practice Location Address: 
2136 W 95TH ST
    Provider Second Line Business Practice Location Address: 
SUITE 202
    Provider Business Practice Location Address City Name: 
CHICAGO
    Provider Business Practice Location Address State Name: 
IL
    Provider Business Practice Location Address Postal Code: 
60643-1000
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
773-941-5840
    Provider Business Practice Location Address Fax Number: 
773-941-5856
    Provider Enumeration Date: 
09/18/2009