| NPI | 1255634234 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | THOMAS L DONAHUE Doctor/Provider 773-697-0176 |
| Organization Subpart ? | No |
| Primary Taxonomy | 305S00000X Point of Service (Licence: IL 038.009384) |
| Enumeration Date | 2010-12-13 |
| Last Update Date | 2018-06-20 |