Healthcare Provider Details

I. General information

NPI: 1780794610
Provider Name (Legal Business Name): MARY MELILLO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/30/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

307 NOONAN DR
PACIFIC MO
63069-1118
US

IV. Provider business mailing address

3233 HIGHWAY F
DEFIANCE MO
63341-1213
US

V. Phone/Fax

Practice location:
  • Phone: 636-271-9995
  • Fax:
Mailing address:
  • Phone: 636-828-6012
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: