Provider First Line Business Practice Location Address:
1640 W ROOSEVELT RD
Provider Second Line Business Practice Location Address:
ROOM 336 (M/C 628)
Provider Business Practice Location Address City Name:
CHICAGO
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60608-1316
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
312-413-1563
Provider Business Practice Location Address Fax Number:
312-413-1993
Provider Enumeration Date:
10/04/2006