Provider First Line Business Practice Location Address:
4748 N MILWAUKEE AVE
Provider Second Line Business Practice Location Address:
STE 1
Provider Business Practice Location Address City Name:
CHICAGO
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60630-3629
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
773-685-9339
Provider Business Practice Location Address Fax Number:
773-685-6202
Provider Enumeration Date:
04/23/2007