Provider Demographics
NPI:1316956592
Name:MELENDREZ, ALFRED SIMON (PTA)
Entity type:Individual
Prefix:MR
First Name:ALFRED
Middle Name:SIMON
Last Name:MELENDREZ
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1129 N 10TH ST
Mailing Address - Street 2:
Mailing Address - City:COLTON
Mailing Address - State:CA
Mailing Address - Zip Code:92324-2447
Mailing Address - Country:US
Mailing Address - Phone:909-422-1466
Mailing Address - Fax:
Practice Address - Street 1:15707 VALLEY BLVD
Practice Address - Street 2:
Practice Address - City:CITY OF INDUSTRY
Practice Address - State:CA
Practice Address - Zip Code:91744-3932
Practice Address - Country:US
Practice Address - Phone:626-961-1152
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAT3379225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant