Provider Demographics
NPI:1295160984
Name:LUIS, CARLOS DANIEL (ATC)
Entity type:Individual
Prefix:MR
First Name:CARLOS
Middle Name:DANIEL
Last Name:LUIS
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12603 STATE ROUTE 143
Mailing Address - Street 2:STE. #8
Mailing Address - City:HIGHLAND
Mailing Address - State:IL
Mailing Address - Zip Code:62249-1199
Mailing Address - Country:US
Mailing Address - Phone:618-654-4701
Mailing Address - Fax:618-654-4739
Practice Address - Street 1:12603 STATE ROUTE 143
Practice Address - Street 2:STE. #8
Practice Address - City:HIGHLAND
Practice Address - State:IL
Practice Address - Zip Code:62249-1199
Practice Address - Country:US
Practice Address - Phone:618-654-4701
Practice Address - Fax:618-654-4739
Is Sole Proprietor?:No
Enumeration Date:2013-09-12
Last Update Date:2013-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL096.0034502255A2300X
MO20130236272255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer