Provider First Line Business Practice Location Address:
1520 N DAYTON 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:
60642-2522
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
312-380-1822
Provider Business Practice Location Address Fax Number:
312-313-8995
Provider Enumeration Date:
01/09/2008