Provider Demographics
NPI:1780948638
Name:CHACKO, LIJU (CRT)
Entity type:Individual
Prefix:
First Name:LIJU
Middle Name:
Last Name:CHACKO
Suffix:
Gender:M
Credentials:CRT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:313 PAR DR
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19115-1018
Mailing Address - Country:US
Mailing Address - Phone:267-549-1171
Mailing Address - Fax:
Practice Address - Street 1:313 PAR DR
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19115-1018
Practice Address - Country:US
Practice Address - Phone:267-549-1171
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-06-26
Last Update Date:2012-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAYM0137052278G1100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2278G1100XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRespiratory Therapist, CertifiedGeneral Care