Provider Demographics
NPI:1689159048
Name:CHESTER, MICHAEL DAVID (PTA)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:DAVID
Last Name:CHESTER
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:709 WILLOW RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76103-1249
Mailing Address - Country:US
Mailing Address - Phone:682-472-8696
Mailing Address - Fax:
Practice Address - Street 1:2645 W RANDOL MILL RD
Practice Address - Street 2:
Practice Address - City:ARLINGTON
Practice Address - State:TX
Practice Address - Zip Code:76012-4228
Practice Address - Country:US
Practice Address - Phone:817-277-6789
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-01
Last Update Date:2018-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2043248225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant