Healthcare Provider Details

I. General information

NPI: 1609626043
Provider Name (Legal Business Name): MARK LLANTO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/26/2024
Last Update Date: 03/26/2024
Certification Date: 03/26/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18938 JONATHAN LN
HOMEWOOD IL
60430-4228
US

IV. Provider business mailing address

18938 JONATHAN LN
HOMEWOOD IL
60430-4228
US

V. Phone/Fax

Practice location:
  • Phone: 707-592-5405
  • Fax:
Mailing address:
  • Phone: 707-592-5405
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: