Provider First Line Business Practice Location Address:
1516 S WABASH AVE
Provider Second Line Business Practice Location Address:
APT 1104
Provider Business Practice Location Address City Name:
CHICAGO
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60605-2903
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
414-870-5178
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
12/28/2005