Provider First Line Business Practice Location Address:
2357 W CONGRESS PKWY
Provider Second Line Business Practice Location Address:
UNIT 3
Provider Business Practice Location Address City Name:
CHICAGO
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60612-3685
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
312-590-1601
Provider Business Practice Location Address Fax Number:
312-224-0023
Provider Enumeration Date:
09/15/2015