Approved
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Prairie Crossing Living & Rehab
409 West Comanche Avenue • Shabbona, IL 60550
Personal Information
Full Name
*
Address
Zip code
*
Phone Number
Email Address
*
Transaction Details
$
Amount
*
+ Convenience fee
Final Amount
Resident Name
Credit Card Details
Pay with Check
Card Number
*
MMYY
*
CVV
?
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Prairie Crossing Living & Rehab
409 West Comanche Avenue
Shabbona, IL 60550
Tell: 847-982-2300
[response]
ID #[transid]
[created]
[cardholder]
$ [amount]
[cardtype] [ccnum4]
Authorization Number
[authcode]
AVS Response
[avsresult]
CVV response
[cvcresult]
[otherTransaction]
