MEDICARE: MR. ALFRED SIMON MELENDREZ PTA

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	225200000X	Physical Therapy Assistant	AT3379	CA

General Provider Information

NPI Number	:	1316956592
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. ALFRED SIMON MELENDREZ PTA

Provider Business Mailing Address
First Line	:	1129 N 10TH ST
Second Line	:
City	:	COLTON
State	:	CA
Zip	:	92324-2447
Country	:	US
Telephone Number	:	909-422-1466
Fax Number	:

Provider Business Practice Location Address
First Line	:	15707 VALLEY BLVD
Second Line	:
City	:	CITY OF INDUSTRY
State	:	CA
Zip	:	91744-3932
Country	:	US
Telephone Number	:	626-961-1152
Fax Number	:

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

Provider Enumeration Date	:	08/05/2006
Last Update Date	:	07/08/2007

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