Provider First Line Business Practice Location Address:
1919 W ARMITAGE 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:
60622-1176
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
847-420-4206
Provider Business Practice Location Address Fax Number:
312-896-9261
Provider Enumeration Date:
09/10/2025