Provider Demographics
NPI:1407383573
Name:LLERAS, MEL (REV, CHT)
Entity Type:Individual
Prefix:
First Name:MEL
Middle Name:
Last Name:LLERAS
Suffix:
Gender:M
Credentials:REV, CHT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1406 W LAKE ST STE A
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55408-3598
Mailing Address - Country:US
Mailing Address - Phone:612-430-9385
Mailing Address - Fax:
Practice Address - Street 1:1406 W LAKE ST STE A
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55408-3598
Practice Address - Country:US
Practice Address - Phone:612-430-9385
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-05-19
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ374K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374K00000XNursing Service Related ProvidersReligious Nonmedical Practitioner