Provider Demographics
NPI:1245220011
Name:MELLOTT, RYAN JAKE (PT)
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:JAKE
Last Name:MELLOTT
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:95 1ST AVE
Mailing Address - Street 2:
Mailing Address - City:MONTE VISTA
Mailing Address - State:CO
Mailing Address - Zip Code:81144-1070
Mailing Address - Country:US
Mailing Address - Phone:719-852-2512
Mailing Address - Fax:719-852-3923
Practice Address - Street 1:95 1ST AVE
Practice Address - Street 2:
Practice Address - City:MONTE VISTA
Practice Address - State:CO
Practice Address - Zip Code:81144-1069
Practice Address - Country:US
Practice Address - Phone:719-852-2512
Practice Address - Fax:719-852-3923
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-10-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO6891225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO84070694565OtherROCKY MOUNTAIN HEALTH PAN
COME654882OtherANTHEM BCBS