Provider First Line Business Practice Location Address:
3548 N. SOUTHPORT AVE.
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:
66057-1436
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
773-755-9214
Provider Business Practice Location Address Fax Number:
773-755-9216
Provider Enumeration Date:
03/16/2007