Provider First Line Business Practice Location Address: 
5159 S. ASHLAND 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: 
60609-5322
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
773-434-9216
    Provider Business Practice Location Address Fax Number: 
773-434-2670
    Provider Enumeration Date: 
10/31/2006