Healthcare Provider Details

I. General information

NPI: 1114229598
Provider Name (Legal Business Name): OPHELIA RACHELL CHILES
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: OPHELIA RACHELL TRACY

II. Dates (important events)

Enumeration Date: 11/17/2010
Last Update Date: 06/12/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

767 KENSINGTON AVE
PLAINFIELD NJ
07060
US

IV. Provider business mailing address

767 KENSINGTON AVE
PLAINFIELD NJ
07060-1913
US

V. Phone/Fax

Practice location:
  • Phone: 973-941-1123
  • Fax:
Mailing address:
  • Phone: 973-941-1123
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number784299
License Number StateNJ

VII. Legacy identifiers

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: