Provider First Line Business Practice Location Address:
1212 NORTH LAKE SHORE DRIVE
Provider Second Line Business Practice Location Address:
APT #5C SOUTH
Provider Business Practice Location Address City Name:
CHICAGO
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60610-6670
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
312-266-8908
Provider Business Practice Location Address Fax Number:
312-266-8908
Provider Enumeration Date:
11/20/2006