Healthcare Provider Details

I. General information

NPI: 1811633316
Provider Name (Legal Business Name): JESUS CHAVEZ ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/07/2022
Last Update Date: 05/27/2022
Certification Date: 05/27/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

174 CORNELL CIR
PUEBLO CO
81005-1928
US

IV. Provider business mailing address

174 CORNELL CIR
PUEBLO CO
81005-1928
US

V. Phone/Fax

Practice location:
  • Phone: 719-994-8890
  • Fax:
Mailing address:
  • Phone: 719-994-8890
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code225C00000X
TaxonomyRehabilitation Counselor
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: