Healthcare Provider Details

I. General information

NPI: 1609410729
Provider Name (Legal Business Name): THEODORE CHUKWU PTA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/31/2019
Last Update Date: 10/31/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10017 23RD AVE
EAST ELMHURST NY
11369-1305
US

IV. Provider business mailing address

9817 HORACE HARDING EXPY APT 1K
CORONA NY
11368-4224
US

V. Phone/Fax

Practice location:
  • Phone: 718-205-8100
  • Fax:
Mailing address:
  • Phone: 718-685-8432
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number007802
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: