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General NPI Number Information
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NPI Number | 1831210210
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Entity Type | Individual
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Provider Name | MISS MARY J CHACKO
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Gender | Female
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Dates
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Enumeration Date | 04/03/2007
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Last Update Date | 07/08/2007
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Provider Practice Location Address
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Address Line | 944 N HONORE ST
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City | CHICAGO
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State | IL
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Zip | 60622-7133
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Country | US
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Telephone | 909-609-9366
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Fax |
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Provider Business Mailing Address
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Address Line | 1014 S LAUREL ST
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City | WICHITA
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State | KS
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Zip | 67207-3739
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Country | US
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Telephone | 909-609-9366
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225100000X
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Taxonomy Name | Physical Therapist
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License Number | 70015223
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License Number State | IL
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Taxonomy #2
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Taxonomy Code | 225100000X
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Taxonomy Name | Physical Therapist
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License Number | 25159
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License Number State | CA
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