Provider First Line Business Practice Location Address:
1515 S PRAIRIE AVE
Provider Second Line Business Practice Location Address:
UNIT 603
Provider Business Practice Location Address City Name:
CHICAGO
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60605-3043
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
773-733-1695
Provider Business Practice Location Address Fax Number:
773-435-6595
Provider Enumeration Date:
10/23/2009