Provider First Line Business Practice Location Address:
4438 N MIWAUKEE 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:
60630-6063
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
773-205-8200
Provider Business Practice Location Address Fax Number:
773-205-1222
Provider Enumeration Date:
09/17/2006