Provider First Line Business Practice Location Address:
5530 S ELLIS AVE
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:
60637-1402
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
773-702-3882
Provider Business Practice Location Address Fax Number:
773-834-4470
Provider Enumeration Date:
03/14/2006