Facts
- Status
- A
- Credential
- LSW
- Type
- Individual
- Enumeration date
- 2019-08-07
- Last updated
- 2019-08-07
Specialties
Licenses
- License IL
- 150103833
Location
- Practice location
- 5000 S 5TH AVE BLDG 200
- City
- HINES IL
- Postal code
- 601413030
- Phone
- 708-202-5678
Medicare
- PECOS
- No PECOS enrollment row matched this NPI.
LEIE
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Nearby
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Removal request
Public data from NPPES and CMS. Not a credentialing determination.