Provider First Line Business Practice Location Address:
3008 S HALSTED ST
Provider Second Line Business Practice Location Address:
SUITE 116
Provider Business Practice Location Address City Name:
CHICAGO
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60608-5805
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
312-842-1205
Provider Business Practice Location Address Fax Number:
312-842-1356
Provider Enumeration Date:
11/29/2005