Healthcare Provider Details

I. General information

NPI: 1699233676
Provider Name (Legal Business Name): CHAD GARY MOODY CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/08/2019
Last Update Date: 03/08/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 EAST BLVD
ELKHART IN
46514-2483
US

IV. Provider business mailing address

15898 MARCELLO CIR
NAPLES FL
34110-2832
US

V. Phone/Fax

Practice location:
  • Phone: 801-462-5485
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number125899
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: