1689635864 NPI number — MARY V CHANCE APN

Table of content: MARY V CHANCE APN (NPI 1689635864)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1689635864 NPI number — MARY V CHANCE APN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CHANCE
Provider First Name:
MARY
Provider Middle Name:
V
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
APN
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
JENKINS
Provider Other First Name:
MARY
Provider Other Middle Name:
V
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1689635864
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/28/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
969 NORTHWYCK DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LIBERTY
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
64068-3354
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
601 S 169 HWY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SMITHVILLE
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
64089-9317
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
816-461-8288
Provider Business Practice Location Address Fax Number:
816-461-6586
Provider Enumeration Date:
03/29/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 2084P0800X , with the licence number:  104029 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 200305140A , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".
  • Identifier: 429019003 , issued by the state of ( KS ) . This identifiers is of the category "MEDICAID".




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