Provider First Line Business Practice Location Address:
1900 W POLK ST
Provider Second Line Business Practice Location Address:
ADMIN BLDG, 5TH FLOOR, RM 519
Provider Business Practice Location Address City Name:
CHICAGO
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60612-3723
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
312-864-4478
Provider Business Practice Location Address Fax Number:
312-864-9663
Provider Enumeration Date:
11/22/2006