Provider First Line Business Practice Location Address: 
1953 N CLYBOURN AVE
    Provider Second Line Business Practice Location Address: 
UNIT S
    Provider Business Practice Location Address City Name: 
CHICAGO
    Provider Business Practice Location Address State Name: 
IL
    Provider Business Practice Location Address Postal Code: 
60614-4945
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
773-871-3100
    Provider Business Practice Location Address Fax Number: 
773-871-7388
    Provider Enumeration Date: 
02/12/2007