Healthcare Provider Details

I. General information

NPI: 1659967917
Provider Name (Legal Business Name): MITAS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/21/2020
Last Update Date: 09/02/2025
Certification Date: 09/25/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1191 FORTUNE BLVD STE 2
SHILOH IL
62269-7474
US

IV. Provider business mailing address

1191 FORTUNE BLVD STE 2
SHILOH IL
62269-7474
US

V. Phone/Fax

Practice location:
  • Phone: 404-580-8511
  • Fax:
Mailing address:
  • Phone: 404-580-8511
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State

VIII. Authorized Official

Name: SWASTIK SINHA
Title or Position: OWNER
Credential: M.D.
Phone: 618-713-5211