Provider First Line Business Practice Location Address:
1605 E 55TH ST
Provider Second Line Business Practice Location Address:
1ST FLR
Provider Business Practice Location Address City Name:
CHICAGO
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60615-5803
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
773-363-0202
Provider Business Practice Location Address Fax Number:
773-363-0201
Provider Enumeration Date:
05/20/2007