Provider First Line Business Practice Location Address:
845 W WILSON AVE
Provider Second Line Business Practice Location Address:
ATTN: CREDENTIALING DPT
Provider Business Practice Location Address City Name:
CHICAGO
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60640-8090
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
773-506-4283
Provider Business Practice Location Address Fax Number:
773-506-4847
Provider Enumeration Date:
06/15/2011