Healthcare Provider Details

I. General information

NPI: 1154586451
Provider Name (Legal Business Name): ALFONSO GENERALAO LLANTO MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/25/2008
Last Update Date: 07/25/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3973 M140
WATERVLIET MI
49098
US

IV. Provider business mailing address

POB 127
WATERVLIET MI
49098
US

V. Phone/Fax

Practice location:
  • Phone: 269-463-5711
  • Fax: 269-463-2885
Mailing address:
  • Phone: 269-463-5711
  • Fax: 269-463-2885

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberAL038737
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: