Healthcare Provider Details

I. General information

NPI: 1750484556
Provider Name (Legal Business Name): ALFONSO G LLANTO MD PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/07/2006
Last Update Date: 06/23/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3973 M 140
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 Code208D00000X
TaxonomyGeneral Practice Physician
License NumberAL038737
License Number StateMI

VIII. Authorized Official

Name: MRS. JOSEPHINE A LLANTO
Title or Position: OFFICE MANAGER
Credential:
Phone: 269-463-5711