Provider First Line Business Practice Location Address: 
850 W NORTH AVE
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
MELROSE PARK
    Provider Business Practice Location Address State Name: 
IL
    Provider Business Practice Location Address Postal Code: 
60160-1611
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
708-338-2795
    Provider Business Practice Location Address Fax Number: 
708-338-2795
    Provider Enumeration Date: 
07/24/2006