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"FirstLineMailingAddress": "7655 SOLUTIONS CTR",
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"MailingAddressCityName": "CHICAGO",
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"MailingAddressTelephoneNumber": "557-203-1551",
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"FirstLinePracticeLocationAddress": "2505 MISSION DR",
"SecondLinePracticeLocationAddress": "SUITE 210",
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"EnumerationDate": "02/20/2009",
"LastUpdateDate": "12/16/2025",
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"NPIReactivationDate": null,
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"Gender": null,
"AuthorizedOfficialLastName": "MANUEL",
"AuthorizedOfficialFirstName": "SHASTA",
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"AuthorizedOfficialTelephoneNumber": "405-272-7282",
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}
},
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}
}
}
}