Provider First Line Business Practice Location Address:
225 EAST CHICAGO AVENUE
Provider Second Line Business Practice Location Address:
BOX #152
Provider Business Practice Location Address City Name:
CHICAGO
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60611-2605
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
312-227-0078
Provider Business Practice Location Address Fax Number:
312-227-9525
Provider Enumeration Date:
01/15/2015