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General NPI Number Information
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NPI Number | 1962823138
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Entity Type | Individual
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Provider Name | CHAD DISTELRATH
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Gender | Male
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Dates
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Enumeration Date | 12/13/2013
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Last Update Date | 12/13/2013
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Provider Practice Location Address
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Address Line | 1717 MAPLECREST RD, APT 112
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City | FORT WAYNE
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State | IN
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Zip | 46815
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Country | US
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Telephone | 260-493-0012
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Fax |
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Provider Business Mailing Address
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Address Line | 3825 METER DRIVE
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City | FORT WAYNE
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State | IN
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Zip | 46806
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Country | US
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Telephone |
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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 | 225200000X
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Taxonomy Name | Physical Therapy Assistant
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License Number | 06002033A
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License Number State | IN
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