Provider Demographics
NPI:1912108887
Name:CHETTA, JOHN WILLIAM SULLIVAN (LMT)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:WILLIAM SULLIVAN
Last Name:CHETTA
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:108 DEVON DR
Mailing Address - Street 2:
Mailing Address - City:MANDEVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:70448-3406
Mailing Address - Country:US
Mailing Address - Phone:985-966-9651
Mailing Address - Fax:
Practice Address - Street 1:311 W 21ST AVE
Practice Address - Street 2:
Practice Address - City:COVINGTON
Practice Address - State:LA
Practice Address - Zip Code:70433-3153
Practice Address - Country:US
Practice Address - Phone:985-898-2707
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA8448172M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172M00000XOther Service ProvidersMechanotherapist