MEDICARE: JASMINE CHABOLLA PTA

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	225200000X	Physical Therapy Assistant	2103189	TX

General Provider Information

NPI Number	:	1780093179
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JASMINE CHABOLLA PTA

Provider Business Mailing Address
First Line	:	PO BOX 11538
Second Line	:
City	:	KILLEEN
State	:	TX
Zip	:	76547-1538
Country	:	US
Telephone Number	:	254-245-9177
Fax Number	:	254-245-9178

Provider Business Practice Location Address
First Line	:	101B W CENTRAL TEXAS EXPY # B
Second Line	:	SUITE D
City	:	HARKER HEIGHTS
State	:	TX
Zip	:	76548-1704
Country	:	US
Telephone Number	:	254-630-1186
Fax Number	:	254-213-9235

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

Provider Enumeration Date	:	08/11/2014
Last Update Date	:	08/11/2014

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