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35 Gaylord St.
Elk Grove Village, IL 60007
Tel: 8479798184
Fax: 8479798284BILLING INFORMATIONPATIENT NAME LACTATE OF BIRTHRATE OF INSUREDS# OF INSUREDRELATIONSHIP TO PATIENTCITYSTATE
PHYSICIAN
ACCOUNT001
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004
005
006
007
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009PATIENTMEDICARECOLLECTED
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