Provider First Line Business Practice Location Address:
1640 W. ROOSEVELT RD.
Provider Second Line Business Practice Location Address:
415 DHSP (MC 726)
Provider Business Practice Location Address City Name:
CHICAGO
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60608
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
507-313-1007
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/30/2019