Individual
WILSON KIBUNGEI MALIT
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
OTR/L
Contact information
Practice address
555 W CARPENTER ST, SPRINGFIELD, IL 62702-4905
(217) 525-1880
Mailing address
605 KENYON DR, SPRINGFIELD, IL 62704-1412
(217) 416-0272
Taxonomy
Speciality
Code
Description
License number
State
171W00000X
Contractor
Primary
056003593
IL
Other
Enumeration date
03/19/2013
Last updated
03/19/2013
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