Provider Demographics
NPI:1215455027
Name:DIMLA, JAN CLARENCE GUTIERREZ (PT)
Entity type:Individual
Prefix:MR
First Name:JAN CLARENCE
Middle Name:GUTIERREZ
Last Name:DIMLA
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:702 LURIA LN
Mailing Address - Street 2:
Mailing Address - City:CHAMPAIGN
Mailing Address - State:IL
Mailing Address - Zip Code:61822-1107
Mailing Address - Country:US
Mailing Address - Phone:217-550-9634
Mailing Address - Fax:
Practice Address - Street 1:14792 CATLIN TILTON RD
Practice Address - Street 2:
Practice Address - City:DANVILLE
Practice Address - State:IL
Practice Address - Zip Code:61834-5116
Practice Address - Country:US
Practice Address - Phone:217-443-6430
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-31
Last Update Date:2017-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070022794225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist