Provider Demographics
NPI:1932713104
Name:CHACKO, BIBIN
Entity Type:Individual
Prefix:MR
First Name:BIBIN
Middle Name:
Last Name:CHACKO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1548 CANAL FARM LN APT 6C
Mailing Address - Street 2:
Mailing Address - City:LOS BANOS
Mailing Address - State:CA
Mailing Address - Zip Code:93635-4430
Mailing Address - Country:US
Mailing Address - Phone:310-874-7766
Mailing Address - Fax:
Practice Address - Street 1:535 PEREGRINE DR
Practice Address - Street 2:
Practice Address - City:PATTERSON
Practice Address - State:CA
Practice Address - Zip Code:95363-8703
Practice Address - Country:US
Practice Address - Phone:209-892-4710
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-03
Last Update Date:2020-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist