Healthcare Provider Details

I. General information

NPI: 1780398776
Provider Name (Legal Business Name): CHASE DANIEL MULLIS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/13/2023
Last Update Date: 01/13/2023
Certification Date: 01/10/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

51ST MEDICAL GROUP, 777 SONGTAN BOULVARD, UNIT 2060
APO AE
96278-3627
US

IV. Provider business mailing address

51ST MEDICAL GROUP, 777 SONGTAN BOULVARD, UNIT 2060
APO AE
96278-3627
US

V. Phone/Fax

Practice location:
  • Phone: 315-784-3627
  • Fax:
Mailing address:
  • Phone: 315-784-3627
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code374700000X
TaxonomyTechnician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: