Basic Information
| Provider Information | |||||||||
| NPI: | 1316674112 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | VELASCO | ||||||||
| FirstName: | ILDE BOY | ||||||||
| MiddleName: | TAN | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | PT, DPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4503 E FOXMOOR LN | ||||||||
| Address2: | |||||||||
| City: | LAFAYETTE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 479058562 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7654219840 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3500 CENTURY DR | ||||||||
| Address2: | |||||||||
| City: | GRANITE CITY | ||||||||
| State: | IL | ||||||||
| PostalCode: | 620402166 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6188772700 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/02/2022 | ||||||||
| LastUpdateDate: | 08/02/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 07/30/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.