Individual
RUSTICO MALLILLIN
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Contact information
Practice address
3446 MCKELVEY RD, BRIDGETON, MO 63044-2525
(314) 298-0353
Mailing address
25 GLORIA LN, SAINT PETERS, MO 63376-2157
(314) 550-9996
Taxonomy
Speciality
Code
Description
License number
State
225100000X
Physical Therapist
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
2002006272
LICENSE #
MO
Enumeration date
09/08/2006
Last updated
07/08/2007
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