Provider First Line Business Practice Location Address:
1611 W HARRISON ST
Provider Second Line Business Practice Location Address:
SUITE 212
Provider Business Practice Location Address City Name:
CHICAGO
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60612-4861
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
312-942-4040
Provider Business Practice Location Address Fax Number:
312-563-2545
Provider Enumeration Date:
07/13/2006