Healthcare Provider Details

I. General information

NPI: 1013150762
Provider Name (Legal Business Name): AILANTO, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/10/2009
Last Update Date: 04/10/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3003 E 98TH ST SUITE 261
INDIANAPOLIS IN
46280-1998
US

IV. Provider business mailing address

3003 E 98TH ST SUITE 261
INDIANAPOLIS IN
46280-1998
US

V. Phone/Fax

Practice location:
  • Phone: 866-315-2787
  • Fax: 866-315-7638
Mailing address:
  • Phone: 866-315-2787
  • Fax: 866-315-7638

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number01033610A
License Number StateIN

VIII. Authorized Official

Name: ROGER SPAHR
Title or Position: DIRECTOR
Credential: M.D.
Phone: 866-315-2787