Provider First Line Business Practice Location Address:
2220 S KEDVALE AVE
Provider Second Line Business Practice Location Address:
SUITE 1
Provider Business Practice Location Address City Name:
CHICAGO
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60623-2812
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
773-983-4495
Provider Business Practice Location Address Fax Number:
773-752-7739
Provider Enumeration Date:
07/18/2007