Provider First Line Business Practice Location Address:
1226 S CANAL 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:
60607-5213
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
312-733-8958
Provider Business Practice Location Address Fax Number:
312-733-9447
Provider Enumeration Date:
06/06/2008