Provider First Line Business Practice Location Address:
820 S. DAMEN AV
Provider Second Line Business Practice Location Address:
MP 118
Provider Business Practice Location Address City Name:
CHICAGO
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60612
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
312-569-7673
Provider Business Practice Location Address Fax Number:
312-569-6141
Provider Enumeration Date:
02/25/2008