Provider First Line Business Practice Location Address:
3337 N HARLEM 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:
60634-3602
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
773-481-2772
Provider Business Practice Location Address Fax Number:
773-481-2742
Provider Enumeration Date:
08/27/2012