Provider Demographics
NPI:1902202799
Name:CHACON, LUIS (OTA)
Entity Type:Individual
Prefix:
First Name:LUIS
Middle Name:
Last Name:CHACON
Suffix:
Gender:M
Credentials:OTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:600 W GREGORY ST
Mailing Address - Street 2:
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32502-4744
Mailing Address - Country:US
Mailing Address - Phone:850-437-3131
Mailing Address - Fax:850-262-4191
Practice Address - Street 1:600 W GREGORY ST
Practice Address - Street 2:
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32502-4744
Practice Address - Country:US
Practice Address - Phone:850-437-3131
Practice Address - Fax:850-262-4191
Is Sole Proprietor?:Yes
Enumeration Date:2014-11-06
Last Update Date:2014-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11127224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant