Provider First Line Business Practice Location Address:
3034 W WELLINGTON AVE APT 1
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:
60618-8561
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
412-961-3822
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/25/2026