Provider Demographics
NPI:1215111216
Name:DE CHAVEZ, AVELINO VERGARA (RPT)
Entity type:Individual
Prefix:
First Name:AVELINO
Middle Name:VERGARA
Last Name:DE CHAVEZ
Suffix:
Gender:M
Credentials:RPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11949 UNION TPKE APT 4C
Mailing Address - Street 2:
Mailing Address - City:FOREST HILLS
Mailing Address - State:NY
Mailing Address - Zip Code:11375-6109
Mailing Address - Country:US
Mailing Address - Phone:718-544-2552
Mailing Address - Fax:
Practice Address - Street 1:11949 UNION TPKE APT 4C
Practice Address - Street 2:
Practice Address - City:FOREST HILLS
Practice Address - State:NY
Practice Address - Zip Code:11375-6109
Practice Address - Country:US
Practice Address - Phone:718-544-2552
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-27
Last Update Date:2007-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY015949-1225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist