Provider Demographics
NPI:1093024739
Name:INTARACHOTE, CHALINEE JILL (DPT)
Entity Type:Individual
Prefix:
First Name:CHALINEE
Middle Name:JILL
Last Name:INTARACHOTE
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:JILL
Other - Middle Name:
Other - Last Name:INTARACHOTE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DPT
Mailing Address - Street 1:2801 ALTON PKWY APT 325
Mailing Address - Street 2:
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92606-2179
Mailing Address - Country:US
Mailing Address - Phone:909-573-4521
Mailing Address - Fax:
Practice Address - Street 1:360 SAN MIGUEL DR
Practice Address - Street 2:301
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92660-7853
Practice Address - Country:US
Practice Address - Phone:949-759-0300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-29
Last Update Date:2016-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA36239208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ30106ZMedicare PIN
CACA138098Medicare PIN