Provider First Line Business Practice Location Address:
2743 W CONGRESS PKWY
Provider Second Line Business Practice Location Address:
UNIT GW
Provider Business Practice Location Address City Name:
CHICAGO
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60612-3485
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
773-766-9008
Provider Business Practice Location Address Fax Number:
773-696-1170
Provider Enumeration Date:
04/01/2015