Provider Demographics
NPI:1083809354
Name:CHEBULTZ, JOHN B (MA)
Entity Type:Individual
Prefix:MR
First Name:JOHN
Middle Name:B
Last Name:CHEBULTZ
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12304 SANTA MONICA BLVD
Mailing Address - Street 2:SUITE 300
Mailing Address - City:W LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90025-2551
Mailing Address - Country:US
Mailing Address - Phone:310-288-1650
Mailing Address - Fax:
Practice Address - Street 1:12304 SANTA MONICA BLVD
Practice Address - Street 2:SUITE 300
Practice Address - City:W LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90025-2551
Practice Address - Country:US
Practice Address - Phone:310-288-1650
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-10
Last Update Date:2007-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA46038225500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225500000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/Technologist