Healthcare Provider Details

I. General information

NPI: 1225589336
Provider Name (Legal Business Name): CHANCE TIBBS APSS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/24/2016
Last Update Date: 10/24/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

195 COUNTY ROAD 1024
CUNNINGHAM KY
42035-9324
US

IV. Provider business mailing address

195 COUNTY ROAD 1024
CUNNINGHAM KY
42035-9324
US

V. Phone/Fax

Practice location:
  • Phone: 270-442-7121
  • Fax: 270-933-1056
Mailing address:
  • Phone: 270-442-7121
  • Fax: 270-933-1056

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: