Provider First Line Business Practice Location Address:
5641 W IRVING PARK RD
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:
60634-2742
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
773-282-2520
Provider Business Practice Location Address Fax Number:
773-282-7970
Provider Enumeration Date:
08/17/2009