Provider Demographics
NPI:1558993469
Name:MONTESCLAROS, MARLO
Entity Type:Individual
Prefix:
First Name:MARLO
Middle Name:
Last Name:MONTESCLAROS
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 1:31W061 WOLSFELD DR
Mailing Address - Street 2:
Mailing Address - City:ELGIN
Mailing Address - State:IL
Mailing Address - Zip Code:60120-7404
Mailing Address - Country:US
Mailing Address - Phone:224-628-8990
Mailing Address - Fax:
Practice Address - Street 1:31W061 WOLSFELD DR
Practice Address - Street 2:
Practice Address - City:ELGIN
Practice Address - State:IL
Practice Address - Zip Code:60120-7404
Practice Address - Country:US
Practice Address - Phone:224-628-8990
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-08
Last Update Date:2020-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070.007380225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist