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NPI Code Detail

MEDICARE: JESSE CHAVEZ ATC, LAT

MEDICARE: JESSE CHAVEZ ATC, LAT
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
12255A2300XAthletic Trainer722OK

General Provider Information

NPI Number : 1003225863
Entity Type Code : Individual
Provider Name (Legal Business Name) : JESSE CHAVEZ ATC, LAT
Provider Business Mailing Address
First Line : 2601 N KENTUCKY AVE APT 413
Second Line :
City : OKLAHOMA CITY
State : OK
Zip : 73106-1282
Country : US
Telephone Number :
Fax Number :
Provider Business Practice Location Address
First Line : 2501 N BLACKWELDER AVE
Second Line :
City : OKLAHOMA CITY
State : OK
Zip : 73106-1402
Country : US
Telephone Number : 405-208-6500
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 08/06/2014
Last Update Date : 08/06/2014

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Directions to “ JESSE CHAVEZ ATC, LAT” Practice Location

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