Healthcare Provider Details

I. General information

NPI: 1457263071
Provider Name (Legal Business Name): LEONARD C WANTA PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/18/2026
Last Update Date: 09/18/2026
Certification Date: 09/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

316 E 14TH ST
TILTON IL
61832-7600
US

IV. Provider business mailing address

1364 NOTRE DAME DR
LEMONT IL
60439-8527
US

V. Phone/Fax

Practice location:
  • Phone: 630-789-8962
  • Fax:
Mailing address:
  • Phone: 630-915-6816
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: LEONARD CHESTIN WANTA
Title or Position: PRESIDENT
Credential: DPT
Phone: 630-789-8962