Provider First Line Business Practice Location Address:
5703 S KENWOOD 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:
60637-1718
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
773-363-8313
Provider Business Practice Location Address Fax Number:
773-288-7911
Provider Enumeration Date:
07/10/2006