Individual
OMAR FONSECA
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Contact information
Practice address
2000 LAKE AVE, WOODSTOCK, IL 60098-7401
(815) 206-3388
Mailing address
277 DEERPATH DR, GENOA CITY, WI 53128-2504
Taxonomy
Speciality
Code
Description
License number
State
225200000X
Physical Therapy Assistant
Primary
160.009394
IL
Other
Enumeration date
12/15/2021
Last updated
12/15/2021
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