Provider First Line Business Practice Location Address:
2133 W LEXINGTON ST
Provider Second Line Business Practice Location Address:
2ND FLOOR
Provider Business Practice Location Address City Name:
CHICAGO
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60612-3707
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
312-746-4884
Provider Business Practice Location Address Fax Number:
312-746-6526
Provider Enumeration Date:
10/13/2010