Basic Information
| Provider Information | |||||||||
| NPI: | 1427198449 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CHANDLER FAMILY PRACTICE, PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1076 W CHANDLER BLVD | ||||||||
| Address2: | SUITE 113 | ||||||||
| City: | CHANDLER | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852245225 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4809639334 | ||||||||
| FaxNumber: | 4809630444 | ||||||||
| Practice Location | |||||||||
| Address1: | 1076 W CHANDLER BLVD | ||||||||
| Address2: | SUITE 113 | ||||||||
| City: | CHANDLER | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852245225 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4809639334 | ||||||||
| FaxNumber: | 4809630444 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/07/2007 | ||||||||
| LastUpdateDate: | 05/27/2008 | ||||||||
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| AuthorizedOfficialLastName: | WILSON | ||||||||
| AuthorizedOfficialFirstName: | MARY | ||||||||
| AuthorizedOfficialMiddleName: | L | ||||||||
| AuthorizedOfficialTitleorPosition: | PRACTICE ADMIN. | ||||||||
| AuthorizedOfficialTelephone: | 4809639334 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP2300X | 13278 | AZ | Y | Ambulatory Health Care Facilities | Clinic/Center | Primary Care |
ID Information
| ID | Type | State | Issuer | Description | 251166 | 05 | AZ | MEDICAID |