Facts
- Status
- A
- Credential
- NP
- Type
- Individual
- Enumeration date
- 2014-10-13
- Last updated
- 2020-12-18
Licenses
- License IL
- 041380871
- License IL
- 209-012166
Location
- Practice location
- 214 NORTH SCHUYLER STREET
- City
- LENA IL
- Postal code
- 610488712
- Phone
- 815-369-4541
Medicare
- PECOS
- A PECOS enrollment row matches this NPI.
LEIE
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Nearby
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Removal request
Public data from NPPES and CMS. Not a credentialing determination.