Provider Demographics
NPI:1275941726
Name:MELC PHYSICAL THERAPY SERVICES, INC
Entity Type:Organization
Organization Name:MELC PHYSICAL THERAPY SERVICES, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MARY
Authorized Official - Middle Name:ELLEN
Authorized Official - Last Name:LECLAIR CONNELLY
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:630-212-3419
Mailing Address - Street 1:2 173 LLOYD
Mailing Address - Street 2:
Mailing Address - City:LOMBARD
Mailing Address - State:IL
Mailing Address - Zip Code:60148
Mailing Address - Country:US
Mailing Address - Phone:630-212-3419
Mailing Address - Fax:
Practice Address - Street 1:6360 BELMONT RD
Practice Address - Street 2:
Practice Address - City:DOWNERS GROVE
Practice Address - State:IL
Practice Address - Zip Code:60516-2118
Practice Address - Country:US
Practice Address - Phone:630-212-3419
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-07-29
Last Update Date:2014-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070004645261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy