Provider First Line Business Practice Location Address:
1801 WEST TAYLOR ST
Provider Second Line Business Practice Location Address:
UIC CRANIOFACIAL CENTER
Provider Business Practice Location Address City Name:
CHICAGO
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60612-3617
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
312-237-1602
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/27/2012