MEDICARE: TEQUILA CHANDLER

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	172V00000X	Community Health Worker

General Provider Information

NPI Number	:	1528926516
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TEQUILA CHANDLER

Provider Business Mailing Address
First Line	:	3500 STATE ROAD 38 E STE 300
Second Line	:
City	:	LAFAYETTE
State	:	IN
Zip	:	47905-5167
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	3500 STATE ROAD 38 E STE 300
Second Line	:	1016
City	:	LAFAYETTE
State	:	IN
Zip	:	47905-5167
Country	:	US
Telephone Number	:	219-386-0000
Fax Number	:

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

Provider Enumeration Date	:	01/10/2026
Last Update Date	:	01/10/2026

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Directions to “ TEQUILA CHANDLER ” Practice Location

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