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NPI Code Detail

MEDICARE: CHANEL RAYBON

MEDICARE: CHANEL RAYBON
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
1224Z00000XOccupational Therapy Assistant057005228IL

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1057005228OTHERILLICENSE
2057005228OTHERILSTATE LICENSE

General Provider Information

NPI Number : 1386295863
Entity Type Code : Individual
Provider Name (Legal Business Name) : CHANEL RAYBON
Provider Business Mailing Address
First Line : PO BOX 405
Second Line :
City : MARKHAM
State : IL
Zip : 60428-0405
Country : US
Telephone Number : 708-515-0813
Fax Number :
Provider Business Practice Location Address
First Line : 16726 ORCHARD RIDGE AVE
Second Line :
City : HAZEL CREST
State : IL
Zip : 60429-1242
Country : US
Telephone Number : 708-515-0813
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 09/25/2019
Last Update Date : 09/25/2019

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