Provider Demographics
NPI:1720310550
Name:CHAYJAY LLC
Entity Type:Organization
Organization Name:CHAYJAY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:TERRY
Authorized Official - Middle Name:S
Authorized Official - Last Name:WADE
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:970-249-2118
Mailing Address - Street 1:836 S TOWNSEND AVE, UNIT C
Mailing Address - Street 2:
Mailing Address - City:MONTROSE
Mailing Address - State:CO
Mailing Address - Zip Code:81413
Mailing Address - Country:US
Mailing Address - Phone:970-249-2118
Mailing Address - Fax:970-249-2187
Practice Address - Street 1:836 S TOWNSEND AVE STE C
Practice Address - Street 2:
Practice Address - City:MONTROSE
Practice Address - State:CO
Practice Address - Zip Code:81401-4360
Practice Address - Country:US
Practice Address - Phone:970-249-2118
Practice Address - Fax:970-249-2187
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-02-04
Last Update Date:2010-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO78884284Medicaid
CO6348670001Medicare NSC
COCOA100388Medicare PIN