Provider First Line Business Practice Location Address:
5501 N CLARK 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:
60640-1213
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
773-561-3671
Provider Business Practice Location Address Fax Number:
773-728-1399
Provider Enumeration Date:
07/30/2006