Basic Information
| Provider Information | |||||||||
| NPI: | 1215993175 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LELO | ||||||||
| FirstName: | ANTHONY | ||||||||
| MiddleName: | LOPAKA | ||||||||
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| Credential: | DPT, ATC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 6570 | ||||||||
| Address2: | |||||||||
| City: | PEORIA | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 853856570 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6233988072 | ||||||||
| FaxNumber: | 6233988235 | ||||||||
| Practice Location | |||||||||
| Address1: | 4360 E BROWN RD | ||||||||
| Address2: | SUITE 111 | ||||||||
| City: | MESA | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852054084 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4802220655 | ||||||||
| FaxNumber: | 4802221457 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/20/2006 | ||||||||
| LastUpdateDate: | 03/16/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 7364PT | AZ | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 199399 | 05 | AZ | MEDICAID |