Provider First Line Business Practice Location Address:
4239 W NORTH AVE
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:
60639-5600
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
773-227-1125
Provider Business Practice Location Address Fax Number:
773-227-1151
Provider Enumeration Date:
04/25/2007