Provider Demographics
NPI:1841799525
Name:GALLEGOS, MELVIN
Entity Type:Individual
Prefix:
First Name:MELVIN
Middle Name:
Last Name:GALLEGOS
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 1:3018 S SPAULDING AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60623-4747
Mailing Address - Country:US
Mailing Address - Phone:708-996-5205
Mailing Address - Fax:708-477-4738
Practice Address - Street 1:3018 S SPAULDING AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60623-4747
Practice Address - Country:US
Practice Address - Phone:170-899-6520
Practice Address - Fax:708-996-5205
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-07
Last Update Date:2018-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
172A00000X
ILG42260586028344600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes344600000XTransportation ServicesTaxi
No172A00000XOther Service ProvidersDriver