Provider Demographics
NPI:1710433008
Name:CLAVECILLA, PAUL ALVIN
Entity Type:Individual
Prefix:
First Name:PAUL ALVIN
Middle Name:
Last Name:CLAVECILLA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1099 S MAIN ST
Mailing Address - Street 2:APT. 314
Mailing Address - City:CROWN POINT
Mailing Address - State:IN
Mailing Address - Zip Code:46307-4851
Mailing Address - Country:US
Mailing Address - Phone:847-942-9143
Mailing Address - Fax:
Practice Address - Street 1:1099 SOUTH MAIN ST.
Practice Address - Street 2:APT. 314
Practice Address - City:CROWN POINT
Practice Address - State:IN
Practice Address - Zip Code:46307
Practice Address - Country:US
Practice Address - Phone:847-942-9143
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-28
Last Update Date:2016-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0700206122251G0304X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251G0304XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGeriatrics