Provider Demographics
NPI:1518412006
Name:MELO, MARK
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:MELO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:351 HANCOCK ST
Mailing Address - Street 2:
Mailing Address - City:TIVERTON
Mailing Address - State:RI
Mailing Address - Zip Code:02878-2357
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:120 SEMINARY AVE
Practice Address - Street 2:
Practice Address - City:AUBURNDALE
Practice Address - State:MA
Practice Address - Zip Code:02466-2650
Practice Address - Country:US
Practice Address - Phone:617-663-7000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-24
Last Update Date:2016-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA4081314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility