Provider First Line Business Practice Location Address: 
833 S WOOD ST
    Provider Second Line Business Practice Location Address: 
M-C 886
    Provider Business Practice Location Address City Name: 
CHICAGO
    Provider Business Practice Location Address State Name: 
IL
    Provider Business Practice Location Address Postal Code: 
60612-7229
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
312-996-0898
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
11/14/2006