Provider First Line Business Practice Location Address:
2118 N CAMPBELL AVE
Provider Second Line Business Practice Location Address:
#2
Provider Business Practice Location Address City Name:
CHICAGO
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60647-4102
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
773-551-7581
Provider Business Practice Location Address Fax Number:
773-486-7581
Provider Enumeration Date:
12/12/2006