Healthcare Provider Details

I. General information

NPI: 1861504425
Provider Name (Legal Business Name): MARK RICHARD MELTON P.T.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/31/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1050 S OTSEGO AVE
GAYLORD MI
49735-9171
US

IV. Provider business mailing address

1050 S OTSEGO AVE
GAYLORD MI
49735-9171
US

V. Phone/Fax

Practice location:
  • Phone: 989-731-6781
  • Fax: 989-705-8448
Mailing address:
  • Phone: 989-731-6781
  • Fax: 989-705-8448

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number5501009879
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: