Provider First Line Business Practice Location Address:
5962 N LINCOLN AVE UNIT 4
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:
60659-3711
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
702-969-8694
Provider Business Practice Location Address Fax Number:
702-996-8823
Provider Enumeration Date:
07/02/2026