Provider First Line Business Practice Location Address:
3551 S ARCHER 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:
60609-1135
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
312-774-9136
Provider Business Practice Location Address Fax Number:
312-774-9136
Provider Enumeration Date:
12/15/2025