Healthcare Provider Details

I. General information

NPI: 1841799525
Provider Name (Legal Business Name): MELVIN GALLEGOS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/07/2018
Last Update Date: 02/07/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3018 S SPAULDING AVE
CHICAGO IL
60623-4747
US

IV. Provider business mailing address

3018 S SPAULDING AVE
CHICAGO IL
60623-4747
US

V. Phone/Fax

Practice location:
  • Phone: 170-899-6520
  • Fax: 708-996-5205
Mailing address:
  • Phone: 708-996-5205
  • Fax: 708-477-4738

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code344600000X
TaxonomyTaxi
License NumberG42260586028
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code172A00000X
TaxonomyDriver
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: