Healthcare Provider Details

I. General information

NPI: 1912108887
Provider Name (Legal Business Name): JOHN WILLIAM SULLIVAN CHETTA L.M.T
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/30/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

311 W 21ST AVE
COVINGTON LA
70433-3153
US

IV. Provider business mailing address

108 DEVON DR
MANDEVILLE LA
70448-3406
US

V. Phone/Fax

Practice location:
  • Phone: 985-898-2707
  • Fax:
Mailing address:
  • Phone: 985-966-9651
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172M00000X
TaxonomyMechanotherapist
License Number8448
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: