Provider Demographics
NPI:1427435411
Name:CHELLADURAI, EBENEZER (PT)
Entity type:Individual
Prefix:
First Name:EBENEZER
Middle Name:
Last Name:CHELLADURAI
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:609 PINE CREEK RD
Mailing Address - Street 2:APT C
Mailing Address - City:MAYKING
Mailing Address - State:KY
Mailing Address - Zip Code:41837-9040
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:240 HOSPITAL RD
Practice Address - Street 2:WHITESBURG ARH HOSPITAL
Practice Address - City:WHITESBURG
Practice Address - State:KY
Practice Address - Zip Code:41858
Practice Address - Country:US
Practice Address - Phone:606-633-3500
Practice Address - Fax:606-633-3627
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-29
Last Update Date:2015-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY006575225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist