Provider First Line Business Practice Location Address:
2212 W NORTH AVE
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:
60647-8467
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
312-266-6160
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/12/2006