Provider First Line Business Practice Location Address:
4724 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:
60625-4421
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
773-583-4455
Provider Business Practice Location Address Fax Number:
773-583-8986
Provider Enumeration Date:
04/19/2008