MEDICARE: CHARLES EDWARD CHANEY JR.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	347B00000X	Bus

General Provider Information

NPI Number	:	1013737972
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CHARLES EDWARD CHANEY JR.

Provider Business Mailing Address
First Line	:	340 ROYAL OAK BLVD
Second Line	:
City	:	RICHMOND HTS
State	:	OH
Zip	:	44143-1710
Country	:	US
Telephone Number	:	216-903-0128
Fax Number	:

Provider Business Practice Location Address
First Line	:	17220 OLYMPIA RD
Second Line	:
City	:	CLEVELAND
State	:	OH
Zip	:	44112-1423
Country	:	US
Telephone Number	:	216-903-0128
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/15/2024
Last Update Date	:	10/15/2024

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