Provider First Line Business Practice Location Address:
4820 S GREENWOOD 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:
60615-1914
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
773-624-8181
Provider Business Practice Location Address Fax Number:
773-624-8181
Provider Enumeration Date:
12/09/2005