Healthcare Provider Details

I. General information

NPI: 1528507258
Provider Name (Legal Business Name): MELLEVORE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/14/2017
Last Update Date: 01/23/2020
Certification Date: 01/23/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

935 E 4TH ST
JUNCITON CITY KS
66441
US

IV. Provider business mailing address

1228 WESTLOOP PL #159
MANHATTAN KS
66502-2840
US

V. Phone/Fax

Practice location:
  • Phone: 785-579-6790
  • Fax: 785-579-6792
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number1103031
License Number StateKS
# 2
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number1700445
License Number StateKS
# 3
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number3339
License Number StateKS

VIII. Authorized Official

Name: JEFFREY MATHIS
Title or Position: OWNER
Credential: OTD, CHT
Phone: 785-320-6616