Provider First Line Business Practice Location Address:
5405 S HARLEM 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:
60638-2205
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
773-788-9374
Provider Business Practice Location Address Fax Number:
773-788-9378
Provider Enumeration Date:
11/30/2006