Healthcare Provider Details

I. General information

NPI: 1578296604
Provider Name (Legal Business Name): CHANDLER EADS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/06/2022
Last Update Date: 10/23/2024
Certification Date: 10/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1020 S MAIN ST
SALT LAKE CITY UT
84101-3176
US

IV. Provider business mailing address

3725 W 4100 S STE 201
WEST VALLEY CITY UT
84120-5411
US

V. Phone/Fax

Practice location:
  • Phone: 888-949-4864
  • Fax:
Mailing address:
  • Phone: 888-949-4864
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number12808152-3501
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: