Provider First Line Business Practice Location Address:
15 S KEDZIE 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:
60612-2705
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
773-826-4901
Provider Business Practice Location Address Fax Number:
773-826-4902
Provider Enumeration Date:
02/18/2008