Provider Demographics
NPI:1316263247
Name:FERNANDO, EUGENE VRUCE MENESES (PT)
Entity type:Individual
Prefix:MR
First Name:EUGENE VRUCE
Middle Name:MENESES
Last Name:FERNANDO
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 1:5642 N MAJOR AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60646-6417
Mailing Address - Country:US
Mailing Address - Phone:773-603-8648
Mailing Address - Fax:
Practice Address - Street 1:4920 N. CENTRAL AVENUE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60630-2028
Practice Address - Country:US
Practice Address - Phone:773-205-8911
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-04-16
Last Update Date:2010-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070017638225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist