Provider First Line Business Practice Location Address:
1901 W. HARRISON
Provider Second Line Business Practice Location Address:
ROOM 2620 2ND FLOOR JSH CLINIC N
Provider Business Practice Location Address City Name:
CHICAGO
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60612
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
312-864-3651
Provider Business Practice Location Address Fax Number:
312-864-9173
Provider Enumeration Date:
09/11/2014