Provider First Line Business Practice Location Address:
4700 S HALSTED ST
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:
60609-4416
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
773-927-8777
Provider Business Practice Location Address Fax Number:
773-927-4399
Provider Enumeration Date:
11/19/2011