Provider First Line Business Practice Location Address: 
5517 N KENMORE 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: 
60640-1515
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
773-275-7962
    Provider Business Practice Location Address Fax Number: 
773-275-0728
    Provider Enumeration Date: 
08/06/2013