Provider First Line Business Practice Location Address:
4968 N MILWAUKEE AVE
Provider Second Line Business Practice Location Address:
UNIT 1 S
Provider Business Practice Location Address City Name:
CHICAGO
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60630-2383
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
773-283-4053
Provider Business Practice Location Address Fax Number:
773-283-4588
Provider Enumeration Date:
08/04/2005