Provider First Line Business Practice Location Address:
850 W IRVING PARK 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:
60613-3077
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
773-975-6822
Provider Business Practice Location Address Fax Number:
773-524-7480
Provider Enumeration Date:
08/10/2007