The holder whose full name is Lora-Mir, Fausto R.,come from La Grange IL,hold the Temporary MD Permit license(NO.99017832A) which status is Superceded.
| Name | Lora-Mir, Fausto R. |
|---|---|
| License Number | 99017832A |
| License Type | Temporary MD Permit |
| License Status | Superceded |
| City | La Grange |
| State | IL |