MEDICARE: ROBERT CHAIRES

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
1	390200000X	Student in an Organized Health Care Education/Training Program		NM
2	235Z00000X	Speech-Language Pathologist	PSLP.0000392	CO

General Provider Information

NPI Number	:	1023534229
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ROBERT CHAIRES

Provider Business Mailing Address
First Line	:	5446 N ACADEMY BLVD
Second Line	:
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80918-3644
Country	:	US
Telephone Number	:	719-598-5555
Fax Number	:

Provider Business Practice Location Address
First Line	:	5446 N ACADEMY BLVD
Second Line	:
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80918-3644
Country	:	US
Telephone Number	:	719-598-5555
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/18/2017
Last Update Date	:	11/14/2018

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