Provider First Line Business Practice Location Address:
7132 N HARLEM AVENUE
Provider Second Line Business Practice Location Address:
SUITE 107
Provider Business Practice Location Address City Name:
CHICAGO
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60631-1086
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
773-631-7975
Provider Business Practice Location Address Fax Number:
773-631-7965
Provider Enumeration Date:
07/17/2008