Healthcare Provider Details

I. General information

NPI: 1427435411
Provider Name (Legal Business Name): EBENEZER CHELLADURAI PT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/29/2015
Last Update Date: 04/29/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

240 HOSPITAL RD WHITESBURG ARH HOSPITAL
WHITESBURG KY
41858
US

IV. Provider business mailing address

609 PINE CREEK RD APT C
MAYKING KY
41837-9040
US

V. Phone/Fax

Practice location:
  • Phone: 606-633-3500
  • Fax: 606-633-3627
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number006575
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: