Provider First Line Business Practice Location Address:
1426 W IRVING PARK RD STE 1
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:
60613-5699
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
319-651-4163
Provider Business Practice Location Address Fax Number:
773-935-2595
Provider Enumeration Date:
05/12/2011