Provider First Line Business Practice Location Address:
5600 W ADDISON 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:
60634-4401
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
773-282-7434
Provider Business Practice Location Address Fax Number:
773-794-4676
Provider Enumeration Date:
10/24/2006