1356300842 NPI number — MR. RODOLFO LUCIANO CANTU JR. A.T.C.,L

Table of content: MR. RODOLFO LUCIANO CANTU JR. A.T.C.,L (NPI 1356300842)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1356300842 NPI number — MR. RODOLFO LUCIANO CANTU JR. A.T.C.,L

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CANTU
Provider First Name:
RODOLFO
Provider Middle Name:
LUCIANO
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
JR.
Provider Credential Text:
A.T.C.,L
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1356300842
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
808 ANNE ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WASHINGTON
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
61571-9471
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
309-219-1326
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
456 FULTON ST
Provider Second Line Business Practice Location Address:
SUITE 207
Provider Business Practice Location Address City Name:
PEORIA
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
61602-1274
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
309-680-3764
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/22/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 174400000X , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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