Provider Demographics
NPI:1487374203
Name:MELENDEZ, PHILLIP P
Entity type:Individual
Prefix:
First Name:PHILLIP
Middle Name:P
Last Name:MELENDEZ
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 1:6191 ROADRUNNER LOOP NE
Mailing Address - Street 2:
Mailing Address - City:RIO RANCHO
Mailing Address - State:NM
Mailing Address - Zip Code:87144-5153
Mailing Address - Country:US
Mailing Address - Phone:505-918-8991
Mailing Address - Fax:
Practice Address - Street 1:6191 ROADRUNNER LOOP NE
Practice Address - Street 2:
Practice Address - City:RIO RANCHO
Practice Address - State:NM
Practice Address - Zip Code:87144-5153
Practice Address - Country:US
Practice Address - Phone:505-918-8991
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-31
Last Update Date:2022-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM406108171WH0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171WH0202XOther Service ProvidersContractorHome ModificationsGroup - Single Specialty