MEDICARE: MR. RICARTHUR DANO LONTOC PT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225100000X	Physical Therapist	5501004651	MI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	39028	OTHER	MI	HEALTH PLAN OF MICHIGAN

General Provider Information

NPI Number	:	1881883791
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. RICARTHUR DANO LONTOC PT

Provider Business Mailing Address
First Line	:	PO BOX 8704
Second Line	:
City	:	BENTON HARBOR
State	:	MI
Zip	:	49023-8704
Country	:	US
Telephone Number	:	269-925-9491
Fax Number	:	269-925-9553

Provider Business Practice Location Address
First Line	:	1850 PIPESTONE RD
Second Line	:	STE. 202A
City	:	BENTON HARBOR
State	:	MI
Zip	:	49022-2304
Country	:	US
Telephone Number	:	269-925-9491
Fax Number	:	269-925-9553

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/16/2007
Last Update Date	:	10/16/2007

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