Provider Demographics
NPI:1023553054
Name:ANTILLA, SCOTT (MA)
Entity Type:Individual
Prefix:
First Name:SCOTT
Middle Name:
Last Name:ANTILLA
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 LITCHFIELD AVE SW
Mailing Address - Street 2:
Mailing Address - City:WILLMAR
Mailing Address - State:MN
Mailing Address - Zip Code:56201-3242
Mailing Address - Country:US
Mailing Address - Phone:320-214-1234
Mailing Address - Fax:320-214-1235
Practice Address - Street 1:400 LITCHFIELD AVE SW
Practice Address - Street 2:
Practice Address - City:WILLMAR
Practice Address - State:MN
Practice Address - Zip Code:56201-3242
Practice Address - Country:US
Practice Address - Phone:320-214-1234
Practice Address - Fax:320-214-1235
Is Sole Proprietor?:No
Enumeration Date:2016-12-29
Last Update Date:2016-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171R00000XOther Service ProvidersInterpreter