Healthcare Provider Details

I. General information

NPI: 1679584759
Provider Name (Legal Business Name): MR. EDWARD J. CHACON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/11/2006
Last Update Date: 10/23/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6700 JEFFERSON ST NE SUITE D-2
ALBUQUERQUE NM
87109-4382
US

IV. Provider business mailing address

313 LA ENTRADA RD
LOS LUNAS NM
87031-7617
US

V. Phone/Fax

Practice location:
  • Phone: 505-288-3916
  • Fax:
Mailing address:
  • Phone: 505-620-9213
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1710I1003X
TaxonomyIndependent Duty Medical Technicians
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: