Provider First Line Business Practice Location Address:
2150 W HARRISON ST
Provider Second Line Business Practice Location Address:
RM. 256
Provider Business Practice Location Address City Name:
CHICAGO
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60612
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
312-942-2099
Provider Business Practice Location Address Fax Number:
312-942-3186
Provider Enumeration Date:
07/07/2017