Provider First Line Business Practice Location Address:
1929 W MONTROSE AVE STE 1
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:
60613-1011
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
773-348-6112
Provider Business Practice Location Address Fax Number:
773-348-2136
Provider Enumeration Date:
10/13/2006