Provider First Line Business Practice Location Address: 
7309 S MICHIGAN AVE APT 1B
    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: 
60619-1640
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
773-885-1785
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
01/09/2012