Provider First Line Business Practice Location Address:
3960 N HARLEM 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:
60634-2219
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
773-625-7809
Provider Business Practice Location Address Fax Number:
773-625-7449
Provider Enumeration Date:
10/27/2005