Provider First Line Business Practice Location Address:
UIC, IJR, 1747 WEST ROOSEVELT ROAD, M/C 747
Provider Second Line Business Practice Location Address:
CU 113
Provider Business Practice Location Address City Name:
CHICAGO
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60608
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
312-413-1136
Provider Business Practice Location Address Fax Number:
312-413-4459
Provider Enumeration Date:
01/14/2009