Provider First Line Business Practice Location Address: 
4045 N DAMEN AVE STE 1
    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: 
60618-3277
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
773-296-2766
    Provider Business Practice Location Address Fax Number: 
773-296-2768
    Provider Enumeration Date: 
07/13/2010