Provider Demographics
NPI:1962823138
Name:DISTELRATH, CHAD
Entity Type:Individual
Prefix:
First Name:CHAD
Middle Name:
Last Name:DISTELRATH
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 1:3825 METER DRIVE
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46806
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1717 MAPLECREST RD, APT 112
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46815
Practice Address - Country:US
Practice Address - Phone:260-493-0012
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-12-13
Last Update Date:2013-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN06002033A225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant