Provider First Line Business Practice Location Address: 
2800 N SHERIDAN RD
    Provider Second Line Business Practice Location Address: 
#300
    Provider Business Practice Location Address City Name: 
CHICAGO
    Provider Business Practice Location Address State Name: 
IL
    Provider Business Practice Location Address Postal Code: 
60657-6156
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
773-248-8652
    Provider Business Practice Location Address Fax Number: 
773-248-8647
    Provider Enumeration Date: 
09/05/2011