Provider First Line Business Practice Location Address:
5140 W MELROSE ST
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:
60641-4224
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
773-653-3059
Provider Business Practice Location Address Fax Number:
773-526-7512
Provider Enumeration Date:
12/20/2009