Healthcare Provider Details

I. General information

NPI: 1003295429
Provider Name (Legal Business Name): CHUDLEIGH, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/19/2015
Last Update Date: 05/19/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3724 EXECUTIVE CENTER DR STE 230
AUSTIN TX
78731-1646
US

IV. Provider business mailing address

3724 EXECUTIVE CENTER DR STE 230
AUSTIN TX
78731-1646
US

V. Phone/Fax

Practice location:
  • Phone: 512-452-2100
  • Fax: 855-456-7410
Mailing address:
  • Phone: 512-452-2100
  • Fax: 855-456-7410

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code364SG0600X
TaxonomyGerontology Clinical Nurse Specialist
License NumberF1450
License Number StateTX

VIII. Authorized Official

Name: JAMES C CHUDLEIGH
Title or Position: MEDICAL DIRECTOR
Credential: MD
Phone: 512-452-2100