Provider Demographics
NPI:1487758769
Name:MALLILLIN, RUSTICO
Entity type:Individual
Prefix:
First Name:RUSTICO
Middle Name:
Last Name:MALLILLIN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25 GLORIA LN
Mailing Address - Street 2:
Mailing Address - City:SAINT PETERS
Mailing Address - State:MO
Mailing Address - Zip Code:63376-2157
Mailing Address - Country:US
Mailing Address - Phone:314-550-9996
Mailing Address - Fax:
Practice Address - Street 1:3446 MCKELVEY RD
Practice Address - Street 2:
Practice Address - City:BRIDGETON
Practice Address - State:MO
Practice Address - Zip Code:63044-2525
Practice Address - Country:US
Practice Address - Phone:314-298-0353
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO2002006272OtherLICENSE #