Provider Demographics
NPI:1184110975
Name:CHAVARRIA, JUAN CARLOS (OWNER)
Entity type:Individual
Prefix:
First Name:JUAN
Middle Name:CARLOS
Last Name:CHAVARRIA
Suffix:
Gender:M
Credentials:OWNER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:342 RIVER DR
Mailing Address - Street 2:
Mailing Address - City:GARFIELD
Mailing Address - State:NJ
Mailing Address - Zip Code:07026-3325
Mailing Address - Country:US
Mailing Address - Phone:862-438-1763
Mailing Address - Fax:862-249-4002
Practice Address - Street 1:342 RIVER DR
Practice Address - Street 2:
Practice Address - City:GARFIELD
Practice Address - State:NJ
Practice Address - Zip Code:07026-3325
Practice Address - Country:US
Practice Address - Phone:862-438-1763
Practice Address - Fax:862-249-4002
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-05
Last Update Date:2018-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJC32604156302682343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ82-2706571Medicaid