Provider Demographics
NPI:1629286372
Name:CHAKRABORTY, RAHUL (ST)
Entity Type:Individual
Prefix:MISS
First Name:RAHUL
Middle Name:
Last Name:CHAKRABORTY
Suffix:
Gender:M
Credentials:ST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2400 NORTHWESTERN AVE
Mailing Address - Street 2:
Mailing Address - City:WEST LAFAYETTE BRA
Mailing Address - State:IN
Mailing Address - Zip Code:47906-1855
Mailing Address - Country:US
Mailing Address - Phone:765-427-7793
Mailing Address - Fax:
Practice Address - Street 1:3401 SOLDIERS HOME RD
Practice Address - Street 2:
Practice Address - City:WEST LAFAYETTE BRA
Practice Address - State:IN
Practice Address - Zip Code:47906-1222
Practice Address - Country:US
Practice Address - Phone:765-463-1541
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN46001690A313M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility