Provider First Line Business Practice Location Address:
3634 S PRAIRIE 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:
60653-1009
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
312-523-7258
Provider Business Practice Location Address Fax Number:
773-373-8085
Provider Enumeration Date:
11/08/2012