Individual
DOMICA SHANTA LIGHT
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Contact information
Practice address
202 W PARK AVE, CHAMPAIGN, IL 61820-3929
(217) 373-2430
Mailing address
2602 CARRELTON DR, CHAMPAIGN, IL 61821-4760
(217) 848-2262
Taxonomy
Speciality
Code
Description
License number
State
251B00000X
Case Management Agency
Primary
—
—
Other
Enumeration date
07/05/2011
Last updated
07/05/2011
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