Provider Demographics
NPI:1316674112
Name:VELASCO, ILDE BOY TAN (PT, DPT)
Entity type:Individual
Prefix:MR
First Name:ILDE BOY
Middle Name:TAN
Last Name:VELASCO
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4503 E FOXMOOR LN
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:IN
Mailing Address - Zip Code:47905-8562
Mailing Address - Country:US
Mailing Address - Phone:765-421-9840
Mailing Address - Fax:
Practice Address - Street 1:3500 CENTURY DR
Practice Address - Street 2:
Practice Address - City:GRANITE CITY
Practice Address - State:IL
Practice Address - Zip Code:62040-2166
Practice Address - Country:US
Practice Address - Phone:618-877-2700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-02
Last Update Date:2022-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist