Provider First Line Business Practice Location Address: 
222 MERCHANDISE MART PLZ
    Provider Second Line Business Practice Location Address: 
SUITE951
    Provider Business Practice Location Address City Name: 
CHICAGO
    Provider Business Practice Location Address State Name: 
IL
    Provider Business Practice Location Address Postal Code: 
60654-1103
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
312-855-9206
    Provider Business Practice Location Address Fax Number: 
312-855-9210
    Provider Enumeration Date: 
03/14/2015