Provider First Line Business Practice Location Address:
1506 W HOWARD ST
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:
60626-1708
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
773-465-0695
Provider Business Practice Location Address Fax Number:
773-465-4769
Provider Enumeration Date:
08/01/2006