Provider Demographics
NPI:1770974842
Name:CHACON, JUVENAL ERIC (PT, DPT)
Entity type:Individual
Prefix:
First Name:JUVENAL
Middle Name:ERIC
Last Name:CHACON
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3645 N BEACH ST
Mailing Address - Street 2:
Mailing Address - City:FT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76137-3242
Mailing Address - Country:US
Mailing Address - Phone:817-759-0004
Mailing Address - Fax:817-759-0003
Practice Address - Street 1:3645 N BEACH ST
Practice Address - Street 2:
Practice Address - City:FT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76137-3242
Practice Address - Country:US
Practice Address - Phone:817-759-0004
Practice Address - Fax:814-759-0003
Is Sole Proprietor?:Yes
Enumeration Date:2015-02-11
Last Update Date:2015-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1254951225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist