Provider First Line Business Practice Location Address:
1646 W PRATT BLVD APT 3J
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:
60626-4137
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-380-0412
Provider Business Practice Location Address Fax Number:
208-380-0412
Provider Enumeration Date:
04/11/2025