Basic Information
| Provider Information | |||||||||
| NPI: | 1730782582 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CHAVEZ | ||||||||
| FirstName: | JUSTIN | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
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| Credential: | RBT | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 258831 | ||||||||
| Address2: | |||||||||
| City: | OKLAHOMA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731258831 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7209613764 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 8354 E NORTHFIELD BLVD UNIT 3700 | ||||||||
| Address2: | |||||||||
| City: | DENVER | ||||||||
| State: | CO | ||||||||
| PostalCode: | 802383135 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7209613764 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/16/2020 | ||||||||
| LastUpdateDate: | 11/16/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/16/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106S00000X | 20144949 | CO | Y |
ID Information
| ID | Type | State | Issuer | Description | 20144949 | 01 | RBT | OTHER |