Healthcare Provider Details

I. General information

NPI: 1295137230
Provider Name (Legal Business Name): SHIRAJ CHAKRABORTY PT, DPT, ATC, CSCS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/22/2014
Last Update Date: 09/22/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

239 E KATELLA AVE
ORANGE CA
92867-4853
US

IV. Provider business mailing address

1800 E LAMBERT RD SUITE 220
BREA CA
92821-4370
US

V. Phone/Fax

Practice location:
  • Phone: 714-538-0025
  • Fax: 714-538-3128
Mailing address:
  • Phone: 714-256-5074
  • Fax: 714-256-0770

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number41580
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: