Provider Demographics
NPI:1245569391
Name:CHACON, ODIN (LMT)
Entity Type:Individual
Prefix:
First Name:ODIN
Middle Name:
Last Name:CHACON
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7821 N DALE MABRY HWY
Mailing Address - Street 2:SUITE 106
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33414
Mailing Address - Country:US
Mailing Address - Phone:813-964-6841
Mailing Address - Fax:
Practice Address - Street 1:1400 W 41 ST
Practice Address - Street 2:APT E
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33012
Practice Address - Country:US
Practice Address - Phone:786-663-5630
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-12-21
Last Update Date:2009-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA57465225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist