Provider First Line Business Practice Location Address:
5929 N MILWAUKEE 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:
60646-5419
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
773-631-6887
Provider Business Practice Location Address Fax Number:
773-631-1898
Provider Enumeration Date:
10/20/2005