Healthcare Provider Details

I. General information

NPI: 1093287609
Provider Name (Legal Business Name): IVAN TEODORO CHIA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/20/2018
Last Update Date: 12/20/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

US HWY 491 NORTH
SHIPROCK NM
87420-0160
US

IV. Provider business mailing address

7345 WOODLAND DR STE C
INDIANAPOLIS IN
46278-1737
US

V. Phone/Fax

Practice location:
  • Phone: 505-368-6001
  • Fax:
Mailing address:
  • Phone: 317-286-2885
  • Fax: 317-536-3097

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number718779
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN-80640
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: