Provider First Line Business Practice Location Address:
2335 S WENTWORTH AVE STE B
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:
60616-0117
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
312-566-4545
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/09/2009