Provider Demographics
NPI:1225007107
Name:CHENAULT, JOHN BRADLEY (NBC-HIS; ACA)
Entity type:Individual
Prefix:MR
First Name:JOHN
Middle Name:BRADLEY
Last Name:CHENAULT
Suffix:
Gender:M
Credentials:NBC-HIS; ACA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2112 STONEWALL ST
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:75401-3344
Mailing Address - Country:US
Mailing Address - Phone:903-455-5424
Mailing Address - Fax:903-455-8922
Practice Address - Street 1:2112 STONEWALL ST
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:TX
Practice Address - Zip Code:75401-3344
Practice Address - Country:US
Practice Address - Phone:903-455-5424
Practice Address - Fax:903-455-8922
Is Sole Proprietor?:No
Enumeration Date:2006-03-14
Last Update Date:2012-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX50067225500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225500000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/Technologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX022438801Medicaid
TX1871668970Medicaid
TX528263OtherBLUE CROSS BLUE SHIELD