Provider First Line Business Practice Location Address:
1900 WEST POLK STREET
Provider Second Line Business Practice Location Address:
RM 1134 ADMINISTRATION BUILDING
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:
312-864-9717
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/06/2016