Provider First Line Business Practice Location Address:
10536 S VERNON 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:
60628-2952
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
262-864-3804
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/20/2026