Provider First Line Business Practice Location Address:
2111 W SUPERIOR ST
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:
60612-1315
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
773-895-3411
Provider Business Practice Location Address Fax Number:
312-226-0802
Provider Enumeration Date:
12/05/2006