Provider First Line Business Practice Location Address:
1158 W TAYLOR ST
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:
60607-4213
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
312-455-8640
Provider Business Practice Location Address Fax Number:
312-455-2806
Provider Enumeration Date:
10/20/2006