Provider First Line Business Practice Location Address:
1936 N KIMBALL AVE
Provider Second Line Business Practice Location Address:
APT 1
Provider Business Practice Location Address City Name:
CHICAGO
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60647-3726
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
312-259-8008
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/14/2005