Provider Demographics
NPI:1609147636
Name:ILG, MELINDA BETH (LAT, ATC)
Entity Type:Individual
Prefix:MS
First Name:MELINDA
Middle Name:BETH
Last Name:ILG
Suffix:
Gender:F
Credentials:LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 32861
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28232-2861
Mailing Address - Country:US
Mailing Address - Phone:704-774-7419
Mailing Address - Fax:704-512-3825
Practice Address - Street 1:4400 GOLF ACRES DR
Practice Address - Street 2:BUILDING J SUITE D
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28208-5990
Practice Address - Country:US
Practice Address - Phone:704-774-7419
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-23
Last Update Date:2012-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC13262255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer