=====================================================
General NPI Number Information
=====================================================
NPI Number | 1881165090
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JOHN JEMUJEFF CHUA SELGA DPT
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/16/2018
-----------------------------------------------------
Last Update Date | 11/15/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1075 S IDAHO RD STE 210
-----------------------------------------------------
City | APACHE JUNCTION
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85119-6405
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 480-983-0877
-----------------------------------------------------
Fax | 480-983-3172
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 625 KENMOOR AVE SE STE 100
-----------------------------------------------------
City | GRAND RAPIDS
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49546-2395
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 616-356-5000
-----------------------------------------------------
Fax | 616-356-5001
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | LPT-30626
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | IP-18-08
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------