Provider First Line Business Practice Location Address:
641 W 63RD ST
Provider Second Line Business Practice Location Address:
SPECIALTY CLINIC, LOWER LEVEL
Provider Business Practice Location Address City Name:
CHICAGO
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60621-2032
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
312-745-0662
Provider Business Practice Location Address Fax Number:
312-747-5275
Provider Enumeration Date:
05/02/2007