Healthcare Provider Details

I. General information

NPI: 1760280481
Provider Name (Legal Business Name): TYLER EMERSON MELLECKER PTA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: TYLER EMERSON MELLECKER TYLER E. MELLECKER

II. Dates (important events)

Enumeration Date: 03/06/2025
Last Update Date: 03/06/2025
Certification Date: 03/06/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20973 CORKSCREW SHORES BLVD
ESTERO FL
33928-9146
US

IV. Provider business mailing address

20973 CORKSCREW SHORES BLVD
ESTERO FL
33928-9146
US

V. Phone/Fax

Practice location:
  • Phone: 630-687-0574
  • Fax: 239-320-3231
Mailing address:
  • Phone: 630-687-0574
  • Fax: 239-320-3231

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number27302
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number27302
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: