Individual
LATRECE RUSSELL
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Contact information
Practice address
4734 S PRAIRIE AVE, CHICAGO, IL 60615-1206
(708) 252-1958
Mailing address
4734 S PRAIRIE AVE, UNIT1, CHICAGO, IL 60615-1206
(708) 252-1958
Taxonomy
Speciality
Code
Description
License number
State
247200000X
Other Technician
Primary
—
—
Other
Enumeration date
01/24/2014
Last updated
01/24/2014
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