Provider First Line Business Practice Location Address:
8300 S DORCHESTER AVE
Provider Second Line Business Practice Location Address:
SUITE B
Provider Business Practice Location Address City Name:
CHICAGO
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60619-6402
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
773-731-7923
Provider Business Practice Location Address Fax Number:
773-731-7823
Provider Enumeration Date:
04/10/2007