Provider First Line Business Practice Location Address:
4949 W. IRVING PARK RD.
Provider Second Line Business Practice Location Address:
SUITE E
Provider Business Practice Location Address City Name:
CHICAGO
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60641-2641
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
773-237-4774
Provider Business Practice Location Address Fax Number:
773-202-9902
Provider Enumeration Date:
10/05/2006