Provider First Line Business Practice Location Address:
225 E CHICAGO AVE
Provider Second Line Business Practice Location Address:
BOX 10
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:
312-227-0352
Provider Business Practice Location Address Fax Number:
312-227-9772
Provider Enumeration Date:
12/13/2011