MEDICARE: EDILSAR AMILCAR MELENDRES-GOMES

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	2255A2300X	Athletic Trainer
2	390200000X	Student in an Organized Health Care Education/Training Program

General Provider Information

NPI Number	:	1558112672
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	EDILSAR AMILCAR MELENDRES-GOMES

Provider Business Mailing Address
First Line	:	1445 W CORTEZ ST APT 1
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60642-3933
Country	:	US
Telephone Number	:	925-596-0573
Fax Number	:

Provider Business Practice Location Address
First Line	:	1445 W CORTEZ ST APT 1
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60642-3933
Country	:	US
Telephone Number	:	925-596-0573
Fax Number	:

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

Provider Enumeration Date	:	03/27/2024
Last Update Date	:	03/27/2024

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Directions to “ EDILSAR AMILCAR MELENDRES-GOMES ” Practice Location

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