Healthcare Provider Details

I. General information

NPI: 1750587234
Provider Name (Legal Business Name): MARK L CHANCE FA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/22/2007
Last Update Date: 07/10/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15242 W 82ND TER
LENEXA KS
66219-1501
US

IV. Provider business mailing address

15242 W.82ND TERR
LENEXA KS
66219
US

V. Phone/Fax

Practice location:
  • Phone: 913-541-1228
  • Fax: 913-439-1942
Mailing address:
  • Phone: 913-541-1228
  • Fax: 913-439-1942

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246ZS0410X
TaxonomySurgical Technologist
License Number
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: