Individual
MR. THOMAS WALLER
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Contact information
Practice address
430 E 162ND ST, SUITE 522, SOUTH HOLLAND, IL 60473-2258
(773) 895-3921
(708) 575-0432
Mailing address
430 E 162ND ST, SUITE 522, SOUTH HOLLAND, IL 60473-2258
(773) 895-3921
(708) 575-0432
Taxonomy
Speciality
Code
Description
License number
State
172A00000X
Driver
Primary
W46082583086
IL
Other
Enumeration date
08/15/2008
Last updated
08/15/2008
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