Healthcare Provider Details

I. General information

NPI: 1548857568
Provider Name (Legal Business Name): FRANCISCO LASTA OTR/L, CAPS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/23/2020
Last Update Date: 12/23/2020
Certification Date: 12/23/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1658 W SUPERIOR ST APT 10
CHICAGO IL
60622-7510
US

IV. Provider business mailing address

1658 W SUPERIOR ST APT 10
CHICAGO IL
60622-7510
US

V. Phone/Fax

Practice location:
  • Phone: 312-623-3875
  • Fax:
Mailing address:
  • Phone: 312-623-3875
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XG0600X
TaxonomyGerontology Occupational Therapist
License Number056007883
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: