Provider First Line Business Practice Location Address:
440 E 40TH ST UNIT C
Provider Second Line Business Practice Location Address:
UNIT C
Provider Business Practice Location Address City Name:
CHICAGO
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60653-2755
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
312-296-8626
Provider Business Practice Location Address Fax Number:
312-296-8626
Provider Enumeration Date:
01/10/2026