1255714788 NPI number — CHESTER GRAHAM P.T.

Table of content: CHESTER GRAHAM P.T. (NPI 1255714788)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1255714788 NPI number — CHESTER GRAHAM P.T.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GRAHAM
Provider First Name:
CHESTER
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
P.T.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1255714788
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/01/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
41315 EMERALDA ISLAND RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LEESBURG
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
34788-8337
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
352-669-5632
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3260 WATERMAN WAY
Provider Second Line Business Practice Location Address:
HOME CARE SERVICES
Provider Business Practice Location Address City Name:
TAVARES
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32778-5243
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
352-253-3900
Provider Business Practice Location Address Fax Number:
352-253-3895
Provider Enumeration Date:
07/01/2015

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , with the licence number:  PT3043 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)