Provider First Line Business Practice Location Address:
2139 W BARRY AVE
Provider Second Line Business Practice Location Address:
BASEMENT
Provider Business Practice Location Address City Name:
CHICAGO
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60618-8138
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
773-991-6187
Provider Business Practice Location Address Fax Number:
855-222-5962
Provider Enumeration Date:
01/19/2006