Provider First Line Business Practice Location Address:
3223 S HALSTED 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:
60608-6605
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
312-842-1018
Provider Business Practice Location Address Fax Number:
312-842-1705
Provider Enumeration Date:
07/27/2006