Provider First Line Business Practice Location Address:
5401 S WENTWORTH AVE
Provider Second Line Business Practice Location Address:
SUITE 200
Provider Business Practice Location Address City Name:
CHICAGO
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60609-6300
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
773-538-6191
Provider Business Practice Location Address Fax Number:
773-538-8683
Provider Enumeration Date:
01/30/2007