Provider First Line Business Practice Location Address:
1313 W PRATT BLVD APT 2W
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:
60626-5278
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
623-297-9101
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/29/2026