Provider First Line Business Practice Location Address:
1640 W ROOSEVELT RD
Provider Second Line Business Practice Location Address:
DHSP 538, MC 727
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:
312-413-1871
Provider Business Practice Location Address Fax Number:
312-413-1593
Provider Enumeration Date:
05/18/2021