Provider Demographics
NPI:1235332016
Name:CHALEK, MITCHEL JONATHAN (LAC)
Entity Type:Individual
Prefix:MR
First Name:MITCHEL
Middle Name:JONATHAN
Last Name:CHALEK
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:33 PLYMOUTH ST
Mailing Address - Street 2:SUITE 107
Mailing Address - City:MONTCLAIR
Mailing Address - State:NJ
Mailing Address - Zip Code:07042-2677
Mailing Address - Country:US
Mailing Address - Phone:973-744-7539
Mailing Address - Fax:
Practice Address - Street 1:33 PLYMOUTH ST
Practice Address - Street 2:SUITE 107
Practice Address - City:MONTCLAIR
Practice Address - State:NJ
Practice Address - Zip Code:07042-2677
Practice Address - Country:US
Practice Address - Phone:973-744-7539
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-07
Last Update Date:2011-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MZ00015000171100000X
NY001181-1171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ25MZ00015000OtherLICENCED ACUPUNCTURIST
NY00118-1OtherLICENSED ACUPUNCTURIST