Provider First Line Business Practice Location Address: 
600 S PAULINA ST
    Provider Second Line Business Practice Location Address: 
SUITE 527
    Provider Business Practice Location Address City Name: 
CHICAGO
    Provider Business Practice Location Address State Name: 
IL
    Provider Business Practice Location Address Postal Code: 
60612-3806
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
312-942-5495
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
07/28/2011