Provider Demographics
NPI: | 1568890978 |
---|---|
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: | 630-915-6813 |
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: | 630-654-3088 |
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: | 2013-10-22 |
Last Update Date: | 2013-10-22 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
IL | 070003801 | 253Z00000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 253Z00000X | Agencies | In Home Supportive Care |