MEDICARE: JOSEPH ALBERT DE MESA MONTEMAYOR PT

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	2251G0304X	Geriatric Physical Therapist	070015664	IL

General Provider Information

NPI Number	:	1760879969
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JOSEPH ALBERT DE MESA MONTEMAYOR PT

Provider Business Mailing Address
First Line	:	3639 N OTTAWA AVE
Second Line	:	UNIT 2
City	:	CHICAGO
State	:	IL
Zip	:	60634-3108
Country	:	US
Telephone Number	:	773-844-8231
Fax Number	:

Provider Business Practice Location Address
First Line	:	3639 N OTTAWA AVE
Second Line	:	UNIT 2
City	:	CHICAGO
State	:	IL
Zip	:	60634-3108
Country	:	US
Telephone Number	:	773-844-8231
Fax Number	:

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

Provider Enumeration Date	:	04/25/2015
Last Update Date	:	04/25/2015

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