Healthcare Provider Details

I. General information

NPI: 1356580690
Provider Name (Legal Business Name): CHANDRA LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/10/2009
Last Update Date: 09/01/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20 E MELBOURNE AVE
MELBOURNE FL
32901-5970
US

IV. Provider business mailing address

20 E MELBOURNE AVE STE 104
MELBOURNE FL
32901-5970
US

V. Phone/Fax

Practice location:
  • Phone: 321-951-7404
  • Fax: 321-951-7405
Mailing address:
  • Phone: 321-951-7404
  • Fax: 321-951-7405

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number State

VIII. Authorized Official

Name: DR. RAJIV CHANDRA
Title or Position: MGRM
Credential: MD
Phone: 321-951-7404