Healthcare Provider Details

I. General information

NPI: 1821248840
Provider Name (Legal Business Name): CHASITY L FALLS PAC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/26/2008
Last Update Date: 09/26/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

205 N EAST AVE
JACKSON MI
49201-1753
US

IV. Provider business mailing address

969 OLD PLANK RD
MILFORD MI
48381-2940
US

V. Phone/Fax

Practice location:
  • Phone: 517-788-4811
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number5601005413
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: