Provider First Line Business Practice Location Address:
1420 S PRAIRIE 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:
60605-2884
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
312-218-8479
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/03/2009