Provider Demographics
NPI:1720573801
Name:BANTILAN, ELEGIO
Entity Type:Individual
Prefix:
First Name:ELEGIO
Middle Name:
Last Name:BANTILAN
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 1:525 E BONANZA RD
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89101-3038
Mailing Address - Country:US
Mailing Address - Phone:702-947-4449
Mailing Address - Fax:
Practice Address - Street 1:525 E BONANZA RD
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89101-3038
Practice Address - Country:US
Practice Address - Phone:702-947-4449
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-29
Last Update Date:2018-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health