Provider Demographics
NPI:1689725442
Name:ILLO, ANTHONY R (DC)
Entity Type:Individual
Prefix:DR
First Name:ANTHONY
Middle Name:R
Last Name:ILLO
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7340 SW HUNZIKER ST STE 101
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97223-2303
Mailing Address - Country:US
Mailing Address - Phone:503-624-7249
Mailing Address - Fax:503-684-4178
Practice Address - Street 1:7340 S.W. HUNZIKER ROAD
Practice Address - Street 2:SUITE 101
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97223-2303
Practice Address - Country:US
Practice Address - Phone:503-624-7249
Practice Address - Fax:503-684-4178
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-16
Last Update Date:2008-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR1609111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
R0000QGCFWMedicare PIN