Provider First Line Business Practice Location Address:
5547 N KENMORE 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:
60640-1515
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
773-561-7040
Provider Business Practice Location Address Fax Number:
773-561-7543
Provider Enumeration Date:
06/14/2005