Healthcare Provider Details

I. General information

NPI: 1255110185
Provider Name (Legal Business Name): MS. MELODY FUSE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/28/2023
Last Update Date: 09/28/2023
Certification Date: 09/26/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5052 CLAIREMONT DR UNIT 179125
SAN DIEGO CA
92177-4088
US

IV. Provider business mailing address

5052 CLAIREMONT DR UNIT 179125
SAN DIEGO CA
92177-4088
US

V. Phone/Fax

Practice location:
  • Phone: 619-705-1624
  • Fax:
Mailing address:
  • Phone: 619-705-1624
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225000000X
TaxonomyOrthotic Fitter
License NumberMSBTMEGKUE
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: