MEDICARE: NICHOLE SHAN CHALA PT

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	225100000X	Physical Therapist	1201380	TX

General Provider Information

NPI Number	:	1821709007
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	NICHOLE SHAN CHALA PT

Provider Business Mailing Address
First Line	:	713 PINE VALLEY DR
Second Line	:
City	:	LUFKIN
State	:	TX
Zip	:	75901-7498
Country	:	US
Telephone Number	:	936-208-7003
Fax Number	:

Provider Business Practice Location Address
First Line	:	521 N BRENTWOOD
Second Line	:
City	:	LUFKIN
State	:	TX
Zip	:	75904-7124
Country	:	US
Telephone Number	:	936-632-2639
Fax Number	:

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

Provider Enumeration Date	:	12/08/2022
Last Update Date	:	12/08/2022

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