Provider First Line Business Practice Location Address:
2339B S WENTWORTH 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:
60616-2013
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
312-791-0533
Provider Business Practice Location Address Fax Number:
312-791-0402
Provider Enumeration Date:
05/11/2006