=====================================================
General NPI Number Information
=====================================================
NPI Number | 1609314210
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PRECISION PAIN CARE AND REHABILITATION P.C.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/02/2017
-----------------------------------------------------
Last Update Date | 02/02/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8611 LEFFERTS BLVD SUITE 3B
-----------------------------------------------------
City | RICHMOND HILL
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11418-2536
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-581-5599
-----------------------------------------------------
Fax | 718-880-1374
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1300 UNION TPKE SUITE 203
-----------------------------------------------------
City | NEW HYDE PARK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11040-1764
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-581-5599
-----------------------------------------------------
Fax | 718-880-1374
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | JEFFREY K CHACKO
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 718-581-5599
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208100000X
-----------------------------------------------------
Taxonomy Name | Physical Medicine & Rehabilitation Physician
-----------------------------------------------------
License Number | 256586
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------