Provider First Line Business Practice Location Address:
6853 S HALSTED ST
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:
60621-1896
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
773-224-1336
Provider Business Practice Location Address Fax Number:
773-224-1888
Provider Enumeration Date:
09/20/2006