Provider Demographics
NPI:1639213218
Name:SOLA, AGUSTIN MILLEVO (PT)
Entity Type:Individual
Prefix:
First Name:AGUSTIN
Middle Name:MILLEVO
Last Name:SOLA
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6005 DEMPSTER ST
Mailing Address - Street 2:
Mailing Address - City:MORTON GROVE
Mailing Address - State:IL
Mailing Address - Zip Code:60053-2943
Mailing Address - Country:US
Mailing Address - Phone:847-470-1844
Mailing Address - Fax:847-470-1842
Practice Address - Street 1:6005 DEMPSTER ST
Practice Address - Street 2:
Practice Address - City:MORTON GROVE
Practice Address - State:IL
Practice Address - Zip Code:60053-2943
Practice Address - Country:US
Practice Address - Phone:847-470-1844
Practice Address - Fax:847-470-1842
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist