Provider Demographics
NPI:1407170905
Name:CHACKO, BENNY T
Entity Type:Individual
Prefix:
First Name:BENNY
Middle Name:T
Last Name:CHACKO
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 1:62 BIRCHARD AVE
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10314-4137
Mailing Address - Country:US
Mailing Address - Phone:718-698-4086
Mailing Address - Fax:
Practice Address - Street 1:62 BIRCHARD AVE
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10314-4137
Practice Address - Country:US
Practice Address - Phone:718-698-4086
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-03-26
Last Update Date:2010-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY299431-1164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse