Provider First Line Business Practice Location Address:
1853 WEST POLK STREET
Provider Second Line Business Practice Location Address:
ROOM 109 AT WEST TOWER
Provider Business Practice Location Address City Name:
CHICAGO
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60612
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
312-996-8228
Provider Business Practice Location Address Fax Number:
312-996-8922
Provider Enumeration Date:
02/25/2026