Provider Demographics
NPI:1356300842
Name:CANTU, RODOLFO LUCIANO JR (ATC,L)
Entity type:Individual
Prefix:MR
First Name:RODOLFO
Middle Name:LUCIANO
Last Name:CANTU
Suffix:JR
Gender:M
Credentials:ATC,L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:808 ANNE ST
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:61571-9471
Mailing Address - Country:US
Mailing Address - Phone:309-219-1326
Mailing Address - Fax:
Practice Address - Street 1:456 FULTON ST
Practice Address - Street 2:SUITE 207
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61602-1274
Practice Address - Country:US
Practice Address - Phone:309-680-3764
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist