MEDICARE: FREEBORN MONDELLO

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	12654	CO
2	225100000X	Physical Therapist	4487	NM
3	225100000X	Physical Therapist	21351	MA

General Provider Information

NPI Number	:	1790187631
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	FREEBORN MONDELLO

Provider Business Mailing Address
First Line	:	20 MEADOW HAWK LN
Second Line	:
City	:	SILVER CITY
State	:	NM
Zip	:	88022-9727
Country	:	US
Telephone Number	:	541-951-8170
Fax Number	:

Provider Business Practice Location Address
First Line	:	20 MEADOW HAWK LN
Second Line	:
City	:	SILVER CITY
State	:	NM
Zip	:	88022-9727
Country	:	US
Telephone Number	:	541-951-8170
Fax Number	:

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

Provider Enumeration Date	:	09/23/2014
Last Update Date	:	09/23/2014

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Directions to “ FREEBORN MONDELLO ” Practice Location

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