Provider First Line Business Practice Location Address:
1436 S PRAIRIE AVE UNIT B
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:
60605-3356
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
815-351-2801
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/23/2009