Provider First Line Business Practice Location Address: 
2640 WEST TOUHY AVE
    Provider Second Line Business Practice Location Address: 
SUITE 208
    Provider Business Practice Location Address City Name: 
CHICAGO
    Provider Business Practice Location Address State Name: 
IL
    Provider Business Practice Location Address Postal Code: 
60645-3198
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
773-338-4100
    Provider Business Practice Location Address Fax Number: 
773-338-4200
    Provider Enumeration Date: 
03/03/2011