Provider First Line Business Practice Location Address:
140 S ASHLAND 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:
60607-2402
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
312-850-8434
Provider Business Practice Location Address Fax Number:
312-829-3887
Provider Enumeration Date:
08/13/2006