Provider First Line Business Practice Location Address:
4755 N KENMORE 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:
60640-5015
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
773-262-6892
Provider Business Practice Location Address Fax Number:
773-279-2789
Provider Enumeration Date:
07/21/2006