Provider Demographics
NPI:1558923573
Name:MAGTIRA, MA.CORAZON CLARITO
Entity Type:Individual
Prefix:
First Name:MA.CORAZON
Middle Name:CLARITO
Last Name:MAGTIRA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:840 FOXWORTH BLVD APT 311
Mailing Address - Street 2:
Mailing Address - City:LOMBARD
Mailing Address - State:IL
Mailing Address - Zip Code:60148-4897
Mailing Address - Country:US
Mailing Address - Phone:630-290-0215
Mailing Address - Fax:
Practice Address - Street 1:129 E LAKE ST
Practice Address - Street 2:
Practice Address - City:BLOOMINGDALE
Practice Address - State:IL
Practice Address - Zip Code:60108-1104
Practice Address - Country:US
Practice Address - Phone:630-295-8600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-29
Last Update Date:2019-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL160.008523225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant