Healthcare Provider Details

I. General information

NPI: 1578435822
Provider Name (Legal Business Name): MR. LORENZ CHACKO CHAKKADAVIL
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/18/2025
Last Update Date: 09/18/2025
Certification Date: 09/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7925 WINCHESTER BLVD
QUEENS VILLAGE NY
11427-2128
US

IV. Provider business mailing address

7925 WINCHESTER BLVD
QUEENS VILLAGE NY
11427-2128
US

V. Phone/Fax

Practice location:
  • Phone: 718-264-4050
  • Fax: 718-264-5100
Mailing address:
  • Phone: 718-264-4050
  • Fax: 718-264-5100

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0809X
TaxonomyAdult Psychiatric/Mental Health Registered Nurse
License Number818800-01
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: