Provider Demographics
NPI:1306119102
Name:STARK, ANTHONY JOHN (LPTA)
Entity type:Individual
Prefix:
First Name:ANTHONY
Middle Name:JOHN
Last Name:STARK
Suffix:
Gender:M
Credentials:LPTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3751 ROUND HILL RD
Mailing Address - Street 2:APT 5
Mailing Address - City:SWANSEA
Mailing Address - State:IL
Mailing Address - Zip Code:62226-1222
Mailing Address - Country:US
Mailing Address - Phone:469-939-6867
Mailing Address - Fax:
Practice Address - Street 1:3751 ROUND HILL RD
Practice Address - Street 2:APT 5
Practice Address - City:SWANSEA
Practice Address - State:IL
Practice Address - Zip Code:62226-1222
Practice Address - Country:US
Practice Address - Phone:469-939-6867
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-02-10
Last Update Date:2025-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL160.005649310400000X
TX2067563225200000X, 314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
No310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
No225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant