Provider Demographics
NPI:1134696552
Name:MELENDEZ, AGUSTIN JR (ATC, LAT)
Entity Type:Individual
Prefix:
First Name:AGUSTIN
Middle Name:
Last Name:MELENDEZ
Suffix:JR
Gender:M
Credentials:ATC, LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15651 CHASE HILL BLVD APT 1510
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78256-1070
Mailing Address - Country:US
Mailing Address - Phone:409-457-5817
Mailing Address - Fax:
Practice Address - Street 1:4301 BROADWAY ST
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78209-6318
Practice Address - Country:US
Practice Address - Phone:210-829-3834
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-24
Last Update Date:2018-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAT76922255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXAT7692OtherTEXAS DEPARTMENT OF LICENSING & REGULATION