Individual
REBECCA WADDELL
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Contact information
Practice address
120 BENTON DR, DECATUR, IL 62526-1408
(217) 433-1461
Mailing address
120 BENTON DR, DECATUR, IL 62526-1408
(217) 433-1461
Taxonomy
Speciality
Code
Description
License number
State
347C00000X
Private Vehicle
Primary
W340-7217-9782
IL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
198747636
—
IL
Enumeration date
08/31/2010
Last updated
08/31/2010
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