Provider First Line Business Practice Location Address:
1900 W POLK ST
Provider Second Line Business Practice Location Address:
RM 1208 CREDENTIALS OFFICE C/O JOYCE LAUDERDALE
Provider Business Practice Location Address City Name:
CHICAGO
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60612-3723
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
312-864-0453
Provider Business Practice Location Address Fax Number:
312-864-0460
Provider Enumeration Date:
07/10/2008