Provider First Line Business Practice Location Address:
3001 6TH ST STE A
Provider Second Line Business Practice Location Address:
NAVAL HEALTH CLINIC, BLDG 200-H 9-N MENTAL HEALTH CNTR
Provider Business Practice Location Address City Name:
GREAT LAKES
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60088-2833
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
847-688-2221
Provider Business Practice Location Address Fax Number:
847-688-2697
Provider Enumeration Date:
03/14/2006