Provider First Line Business Practice Location Address:
1126 W PRATT BLVD APT 2N
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:
60626-4418
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
847-780-7044
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/25/2026