Provider First Line Business Practice Location Address:
9501 S DORCHESTER AVE
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:
60628-1720
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
773-463-1313
Provider Business Practice Location Address Fax Number:
773-463-5311
Provider Enumeration Date:
11/20/2009