Healthcare Provider Details

I. General information

NPI: 1134621725
Provider Name (Legal Business Name): JESSE MEJORADA CP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/28/2018
Last Update Date: 02/28/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

401 HARRISON ST
OAK PARK IL
60304-1427
US

IV. Provider business mailing address

1S376 SUMMIT AVE COURT E
OAKBROOK TERRACE IL
60181-3985
US

V. Phone/Fax

Practice location:
  • Phone: 708-383-2257
  • Fax: 708-383-0739
Mailing address:
  • Phone: 630-705-4092
  • Fax: 630-424-0467

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224P00000X
TaxonomyProsthetist
License Number211.000146
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: