Provider Demographics
NPI:1205842556
Name:PANONCILLO, ROLANDO RILE (RPT)
Entity Type:Individual
Prefix:MR
First Name:ROLANDO
Middle Name:RILE
Last Name:PANONCILLO
Suffix:
Gender:M
Credentials:RPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7804 W ADARE DR
Mailing Address - Street 2:
Mailing Address - City:MUNCIE
Mailing Address - State:IN
Mailing Address - Zip Code:47304-9434
Mailing Address - Country:US
Mailing Address - Phone:765-760-4729
Mailing Address - Fax:
Practice Address - Street 1:7804 W ADARE DR
Practice Address - Street 2:
Practice Address - City:MUNCIE
Practice Address - State:IN
Practice Address - Zip Code:47304-9434
Practice Address - Country:US
Practice Address - Phone:765-760-4729
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-31
Last Update Date:2016-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN05004452A174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty