MEDICARE: MR. JOHN CHACKO MOONNUMAKAL

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	163WP0809X	Adult Psychiatric/Mental Health Registered Nurse	534183	TX

General Provider Information

NPI Number	:	1922113448
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. JOHN CHACKO MOONNUMAKAL

Provider Business Mailing Address
First Line	:	3239 MILL HOUSE RUN
Second Line	:
City	:	MISSOURI CITY
State	:	TX
Zip	:	77459-6514
Country	:	US
Telephone Number	:	713-791-1414
Fax Number	:

Provider Business Practice Location Address
First Line	:	3239 MILL HOUSE RUN
Second Line	:
City	:	MISSOURI CITY
State	:	TX
Zip	:	77459-6514
Country	:	US
Telephone Number	:	713-791-1414
Fax Number	:

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

Provider Enumeration Date	:	08/21/2006
Last Update Date	:	07/08/2007

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