MEDICARE: CHANDRA LAVARRE MCINTOSH

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	247200000X	Other Technician

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	247200000X	OTHER	MI	TECHNICIAN

General Provider Information

NPI Number	:	1871043141
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CHANDRA LAVARRE MCINTOSH

Provider Business Mailing Address
First Line	:	18028 FREELAND ST
Second Line	:
City	:	DETROIT
State	:	MI
Zip	:	48235-2571
Country	:	US
Telephone Number	:	313-680-4130
Fax Number	:

Provider Business Practice Location Address
First Line	:	18028 FREELAND ST
Second Line	:
City	:	DETROIT
State	:	MI
Zip	:	48235-2571
Country	:	US
Telephone Number	:	313-680-4130
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/10/2016
Last Update Date	:	10/10/2016

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