Provider Demographics
NPI:1861949992
Name:MACARAIG, MELANI
Entity type:Individual
Prefix:
First Name:MELANI
Middle Name:
Last Name:MACARAIG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:828 N UTAH ST
Mailing Address - Street 2:
Mailing Address - City:WEST PLAINS
Mailing Address - State:MO
Mailing Address - Zip Code:65775-2084
Mailing Address - Country:US
Mailing Address - Phone:708-228-6719
Mailing Address - Fax:
Practice Address - Street 1:1200 N MAIN ST
Practice Address - Street 2:#1
Practice Address - City:MOUNTAIN GROVE
Practice Address - State:MO
Practice Address - Zip Code:65711-1025
Practice Address - Country:US
Practice Address - Phone:417-926-5699
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-09-07
Last Update Date:2016-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2016026054225100000X
IL070.020677225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist