MEDICARE: MR. EUGENE VRUCE MENESES FERNANDO P.T.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225100000X	Physical Therapist	070017638	IL

General Provider Information

NPI Number	:	1316263247
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. EUGENE VRUCE MENESES FERNANDO P.T.

Provider Business Mailing Address
First Line	:	5642 N MAJOR AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60646-6417
Country	:	US
Telephone Number	:	773-603-8648
Fax Number	:

Provider Business Practice Location Address
First Line	:	4920 N. CENTRAL AVENUE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60630-2028
Country	:	US
Telephone Number	:	773-205-8911
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/16/2010
Last Update Date	:	04/16/2010

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