Provider First Line Business Practice Location Address:
2300 CHILDREN'S PLAZA, BOX 57
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:
60614-3394
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
773-880-4643
Provider Business Practice Location Address Fax Number:
773-975-8671
Provider Enumeration Date:
05/24/2006