Provider Demographics
NPI:1629408091
Name:CILLUFFO, ANTHONY JOHN (MS, AT, ATC, CEIS)
Entity Type:Individual
Prefix:
First Name:ANTHONY
Middle Name:JOHN
Last Name:CILLUFFO
Suffix:
Gender:M
Credentials:MS, AT, ATC, CEIS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5376 N LONG LAKE RD
Mailing Address - Street 2:
Mailing Address - City:TRAVERSE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49685-8217
Mailing Address - Country:US
Mailing Address - Phone:231-933-7519
Mailing Address - Fax:
Practice Address - Street 1:821 HASTINGS ST STE 1
Practice Address - Street 2:
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49686-3467
Practice Address - Country:US
Practice Address - Phone:231-753-8004
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-11-20
Last Update Date:2022-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI26010010192255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer