Healthcare Provider Details

I. General information

NPI: 1437111473
Provider Name (Legal Business Name): GERALD GUY LACHANCE DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/05/2006
Last Update Date: 08/09/2024
Certification Date: 08/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1360 BRICKYARD RD
CHIPLEY FL
32428-6303
US

IV. Provider business mailing address

1360 BRICKYARD RD
CHIPLEY FL
32428-6303
US

V. Phone/Fax

Practice location:
  • Phone: 850-415-8303
  • Fax: 207-795-8490
Mailing address:
  • Phone: 850-415-8303
  • Fax: 207-795-8490

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number1707
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: