Provider First Line Business Practice Location Address:
820 SOUTH WOOD STREET CSN 515 UNIVERSITY OF ILLINOIS AT
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:
60612
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
312-996-2779
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/10/2025