Provider Demographics
NPI:1013016559
Name:CHAVEZ, ERNIE CHASIAS (PT)
Entity Type:Individual
Prefix:
First Name:ERNIE
Middle Name:CHASIAS
Last Name:CHAVEZ
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:ERNEST
Other - Middle Name:CASIAS
Other - Last Name:CHAVEZ
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PT
Mailing Address - Street 1:5349 S ADAMS AVE
Mailing Address - Street 2:SUITE A
Mailing Address - City:OGDEN
Mailing Address - State:UT
Mailing Address - Zip Code:84405-4736
Mailing Address - Country:US
Mailing Address - Phone:801-479-9865
Mailing Address - Fax:801-479-5846
Practice Address - Street 1:5349 S ADAMS AVE
Practice Address - Street 2:SUITE A
Practice Address - City:OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84405-4736
Practice Address - Country:US
Practice Address - Phone:801-479-9865
Practice Address - Fax:801-479-5846
Is Sole Proprietor?:No
Enumeration Date:2006-09-21
Last Update Date:2008-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT274724-2401225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT870502207001Medicaid