Basic Information
| Provider Information | |||||||||
| NPI: | 1104181833 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | TABAREJO | ||||||||
| FirstName: | CHRIS JAY | ||||||||
| MiddleName: | JALANDO-ON | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | R.P.T. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 942 COLORADO ST | ||||||||
| Address2: | APARTMENT G | ||||||||
| City: | EAGLE PASS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 788524059 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9548066948 | ||||||||
| FaxNumber: | 8666765890 | ||||||||
| Practice Location | |||||||||
| Address1: | 2483 2ND ST | ||||||||
| Address2: | SUITE B | ||||||||
| City: | EAGLE PASS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 788524390 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8307765191 | ||||||||
| FaxNumber: | 8307765520 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/09/2012 | ||||||||
| LastUpdateDate: | 10/31/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 1217320 | TX | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 1104181833 | 05 | WA | MEDICAID |