| NPI | 1780715292 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | SOL BICOMONG DAYA Medical Doctor 815-444-1913 |
| Organization Subpart ? | No |
| Primary Taxonomy | 305R00000X Preferred Provider Organization (Licence: IL 036048265) |
| Enumeration Date | 2007-03-08 |
| Last Update Date | 2020-08-22 |