Provider First Line Business Practice Location Address:
5248 N MELVINA 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:
60630-1037
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
773-631-1419
Provider Business Practice Location Address Fax Number:
773-631-3110
Provider Enumeration Date:
02/12/2007