Provider First Line Business Practice Location Address:
E. 65TH ST AT LAKE MICHIGAN
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:
60649-1395
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
773-256-5781
Provider Business Practice Location Address Fax Number:
773-363-3481
Provider Enumeration Date:
01/22/2007