Provider Demographics
NPI:1659549202
Name:VALLERO, KEVIN (PT)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:
Last Name:VALLERO
Suffix:
Gender:M
Credentials:PT
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 5387
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:61702-5387
Mailing Address - Country:US
Mailing Address - Phone:309-661-8823
Mailing Address - Fax:309-661-8801
Practice Address - Street 1:765 N KELLOGG ST
Practice Address - Street 2:SUITE 300
Practice Address - City:GALESBURG
Practice Address - State:IL
Practice Address - Zip Code:61401-2875
Practice Address - Country:US
Practice Address - Phone:309-343-3434
Practice Address - Fax:309-343-3456
Is Sole Proprietor?:No
Enumeration Date:2008-02-18
Last Update Date:2008-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070003661225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILR00209Medicare PIN