Provider Demographics
NPI:1225442122
Name:CHAVES, SAMUEL
Entity Type:Individual
Prefix:
First Name:SAMUEL
Middle Name:
Last Name:CHAVES
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:404 S. ELFORD
Mailing Address - Street 2:
Mailing Address - City:DEXTER
Mailing Address - State:NM
Mailing Address - Zip Code:88230
Mailing Address - Country:US
Mailing Address - Phone:575-734-8533
Mailing Address - Fax:
Practice Address - Street 1:404 S. ELFORD
Practice Address - Street 2:
Practice Address - City:DEXTER
Practice Address - State:NM
Practice Address - Zip Code:88230
Practice Address - Country:US
Practice Address - Phone:575-734-8533
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-18
Last Update Date:2014-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM1484225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics