Healthcare Provider Details

I. General information

NPI: 1407865777
Provider Name (Legal Business Name): CHONA G MANABAT P.T.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/05/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24922 EMERALD AVE
PLAINFIELD IL
60585-2968
US

IV. Provider business mailing address

24922 EMERALD AVE
PLAINFIELD IL
60585-2968
US

V. Phone/Fax

Practice location:
  • Phone: 815-272-4563
  • Fax: 815-436-3848
Mailing address:
  • Phone: 815-272-4563
  • Fax: 815-436-3848

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number70011748
License Number StateIL

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier0039941191
Identifier TypeOTHER
Identifier StateIL
Identifier IssuerBCBS PROVIDER #

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: