Provider First Line Business Practice Location Address:
1520 N DAMEN AVE
Provider Second Line Business Practice Location Address:
UNIT A-1
Provider Business Practice Location Address City Name:
CHICAGO
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60622-1967
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
312-605-6434
Provider Business Practice Location Address Fax Number:
312-276-4366
Provider Enumeration Date:
11/21/2012