Provider First Line Business Practice Location Address:
1400 E 47TH ST
Provider Second Line Business Practice Location Address:
SUITE F1-B
Provider Business Practice Location Address City Name:
CHICAGO
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60653-4520
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
773-285-1144
Provider Business Practice Location Address Fax Number:
773-285-1146
Provider Enumeration Date:
06/03/2006