Provider First Line Business Practice Location Address:
1915 S ARCHER 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:
60616-1618
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
312-674-9132
Provider Business Practice Location Address Fax Number:
312-674-9392
Provider Enumeration Date:
04/25/2007