Provider Demographics
NPI:1104382290
Name:ENTIENZA, LOUIE ANTON ANG (RPT)
Entity Type:Individual
Prefix:MR
First Name:LOUIE ANTON
Middle Name:ANG
Last Name:ENTIENZA
Suffix:
Gender:M
Credentials:RPT
Other - Prefix:MR
Other - First Name:LOUIE ANTON
Other - Middle Name:ANG
Other - Last Name:ENTIENZA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:790 REMINGTON BLVD
Mailing Address - Street 2:
Mailing Address - City:BOLINGBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60440-4909
Mailing Address - Country:US
Mailing Address - Phone:224-433-3585
Mailing Address - Fax:
Practice Address - Street 1:7301 PEAK DR STE 101
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89128-9038
Practice Address - Country:US
Practice Address - Phone:702-940-3000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-02-14
Last Update Date:2024-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY044018225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY044018Medicaid