Provider Demographics
NPI:1023564085
Name:LEONARD WANTA SC
Entity Type:Organization
Organization Name:LEONARD WANTA SC
Other - Org Name:DISTINCTIVE THERAPY SERVICES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:LEONARD
Authorized Official - Middle Name:
Authorized Official - Last Name:WANTA
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:630-789-8962
Mailing Address - Street 1:126 CIRCLE RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:BURR RIDGE
Mailing Address - State:IL
Mailing Address - Zip Code:60527-8379
Mailing Address - Country:US
Mailing Address - Phone:630-789-8962
Mailing Address - Fax:
Practice Address - Street 1:126 CIRCLE RIDGE DR
Practice Address - Street 2:
Practice Address - City:BURR RIDGE
Practice Address - State:IL
Practice Address - Zip Code:60527-8379
Practice Address - Country:US
Practice Address - Phone:630-789-8962
Practice Address - Fax:630-654-3088
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-08-30
Last Update Date:2016-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070021814261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy