Provider First Line Business Practice Location Address: 
3270 N LAKE SHORE DR
    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: 
60657-3956
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
917-648-5390
    Provider Business Practice Location Address Fax Number: 
971-200-2395
    Provider Enumeration Date: 
08/08/2009