Provider First Line Business Practice Location Address:
6032 S. HALSTED 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:
60621
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
773-994-7762
Provider Business Practice Location Address Fax Number:
773-994-2912
Provider Enumeration Date:
12/23/2006