Healthcare Provider Details

I. General information

NPI: 1518707876
Provider Name (Legal Business Name): EDGAR CHAVEZ I PTA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: EDGAR CHAVEZ I PTA

II. Dates (important events)

Enumeration Date: 05/25/2024
Last Update Date: 08/19/2026
Certification Date: 08/19/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1120 W ARMY TRAIL BLVD
ADDISON IL
60101-3101
US

IV. Provider business mailing address

1120 W ARMY TRAIL BLVD
ADDISON IL
60101-3101
US

V. Phone/Fax

Practice location:
  • Phone: 630-827-9466
  • Fax:
Mailing address:
  • Phone: 630-827-9466
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number160-009630
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: