Provider First Line Business Practice Location Address:
8106 S. PRAIRIE AVE.
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:
60619-4808
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
773-398-3979
Provider Business Practice Location Address Fax Number:
773-994-2527
Provider Enumeration Date:
01/30/2007