Provider First Line Business Practice Location Address:
4733 N KEDZIE 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:
60625-4420
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
312-550-1415
Provider Business Practice Location Address Fax Number:
331-258-8801
Provider Enumeration Date:
10/13/2026