Healthcare Provider Details

I. General information

NPI: 1558177097
Provider Name (Legal Business Name): MR. CHANCE WALTHER
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/09/2024
Last Update Date: 01/06/2025
Certification Date: 01/06/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

150 DUNCAN RD
BUCKEYE WV
24924-9037
US

IV. Provider business mailing address

PO BOX 242
GREEN BANK WV
24944-0242
US

V. Phone/Fax

Practice location:
  • Phone: 304-799-7400
  • Fax:
Mailing address:
  • Phone: 304-456-5481
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number121689
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: