Provider First Line Business Practice Location Address:
4949 W IRVING PARK RD
Provider Second Line Business Practice Location Address:
SUITE C
Provider Business Practice Location Address City Name:
CHICAGO
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60641-2655
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
773-725-7783
Provider Business Practice Location Address Fax Number:
773-725-7759
Provider Enumeration Date:
03/28/2006