Provider First Line Business Practice Location Address:
4547 S WABASH 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:
60653-3814
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
312-771-6112
Provider Business Practice Location Address Fax Number:
773-373-8994
Provider Enumeration Date:
04/02/2007