Facts
- Status
- A
- Type
- Individual
- Enumeration date
- 2016-03-10
- Last updated
- 2016-10-17
Specialties
Licenses
- License IL
- 146012059
Location
- Practice location
- 310 S MAIN ST STE D
- City
- LOMBARD IL
- Postal code
- 601482692
- Phone
- 630-652-0200
Medicare
- PECOS
- No PECOS enrollment row matched this NPI.
LEIE
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Removal request
Public data from NPPES and CMS. Not a credentialing determination.