Individual
KENDALL DIVANTE LEONARD
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Contact information
Practice address
524 N ROBERTS DR APT 2B, GLENWOOD, IL 60425-2300
(708) 690-4333
Mailing address
3646 147TH PL APT GN, MIDLOTHIAN, IL 60445-3590
(708) 690-4333
Taxonomy
Speciality
Code
Description
License number
State
171W00000X
Contractor
Primary
V00018705
IL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
11295611761
—
IL
Enumeration date
02/24/2020
Last updated
02/24/2020
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