Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 224P00000X | Prosthetist | 211.000146 | IL |
NPI | 1134621725 |
---|---|
Provider Name | Jesse Mejorada |
First Address | Oakbrook Terrace, IL 60181-3985 |
Second Address | Oak Park, IL 60304-1427 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 28/02/2018 |
Last Update Date | 28/02/2018 |