Healthcare Provider Details

I. General information

NPI: 1235612045
Provider Name (Legal Business Name): NATHAN CHUKWULOBE
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/09/2018
Last Update Date: 09/09/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2485 S MAJOR DR
BEAUMONT TX
77707-5019
US

IV. Provider business mailing address

3925 CROW RD APT 36
BEAUMONT TX
77706-7014
US

V. Phone/Fax

Practice location:
  • Phone: 409-861-4611
  • Fax:
Mailing address:
  • Phone: 614-937-3021
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number2120162
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: