Provider First Line Business Practice Location Address:
1335 W BARRY 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:
60657-4211
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
312-919-1229
Provider Business Practice Location Address Fax Number:
847-885-1212
Provider Enumeration Date:
10/23/2007