Provider First Line Business Practice Location Address: 
5140 N CALLIFORNIA AVE
    Provider Second Line Business Practice Location Address: 
540
    Provider Business Practice Location Address City Name: 
CHICAGO
    Provider Business Practice Location Address State Name: 
IL
    Provider Business Practice Location Address Postal Code: 
60625
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
773-293-0922
    Provider Business Practice Location Address Fax Number: 
773-293-0928
    Provider Enumeration Date: 
08/08/2006