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NPI 1538038278 · on the registry since 2025 · sole proprietor

Practice

Address
2000 W Foster Ave Apt 2d
Chicago, IL 60625
Phone
(605) 360-1116

Registry record

Primary taxonomy
156FX1201X
156FX1201X
Licence states on file
IL
From the registry's licence fields, which are often incomplete.
Sex
Male
Record last updated
2025-10-31

Source: CMS National Plan and Provider Enumeration System. Registration is not the same as practising, and the registry records no retirement — some people listed here no longer practise. More in Illinois