Provider First Line Business Practice Location Address: 
17 W GOLF RD
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
DES PLAINES
    Provider Business Practice Location Address State Name: 
IL
    Provider Business Practice Location Address Postal Code: 
60016-2410
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
847-296-5145
    Provider Business Practice Location Address Fax Number: 
847-296-5178
    Provider Enumeration Date: 
09/02/2011