Provider First Line Business Practice Location Address: 
3512 N PULASKI RD
    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: 
60641-3943
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
773-218-6460
    Provider Business Practice Location Address Fax Number: 
773-227-5721
    Provider Enumeration Date: 
01/16/2015