Provider First Line Business Practice Location Address: 
1009 S WOOD ST FL 2
    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: 
60612-3747
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
312-996-2779
    Provider Business Practice Location Address Fax Number: 
312-355-2983
    Provider Enumeration Date: 
01/14/2018