Provider First Line Business Practice Location Address:
2320 N DAMEN AVE
Provider Second Line Business Practice Location Address:
SUITE 1R
Provider Business Practice Location Address City Name:
CHICAGO
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60647-3359
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
773-489-0001
Provider Business Practice Location Address Fax Number:
773-489-0003
Provider Enumeration Date:
07/30/2008