Provider First Line Business Practice Location Address:
1834 W NORTH AVE
Provider Second Line Business Practice Location Address:
SUITE 1
Provider Business Practice Location Address City Name:
CHICAGO
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60622-1312
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
773-227-9150
Provider Business Practice Location Address Fax Number:
773-227-9160
Provider Enumeration Date:
09/29/2008