Individual
MS. TELISA LONG
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Contact information
Practice address
413 INDIANWOOD BLVD, PARK FOREST, IL 60466-2247
(708) 369-2368
(708) 747-5980
Mailing address
413 INDIANWOOD BLVD, PARK FOREST, IL 60466-2247
(708) 369-2368
(708) 747-5980
Taxonomy
Speciality
Code
Description
License number
State
347C00000X
Private Vehicle
Primary
L52081680690
IL
Other
Enumeration date
08/11/2009
Last updated
08/11/2009
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