Provider Demographics
NPI:1073389847
Name:MERTGEN, CHANCE
Entity Type:Individual
Prefix:
First Name:CHANCE
Middle Name:
Last Name:MERTGEN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1728 JESSE JAMES CT
Mailing Address - Street 2:
Mailing Address - City:BOONVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:65233-2874
Mailing Address - Country:US
Mailing Address - Phone:573-540-7160
Mailing Address - Fax:
Practice Address - Street 1:1728 JESSE JAMES CT
Practice Address - Street 2:
Practice Address - City:BOONVILLE
Practice Address - State:MO
Practice Address - Zip Code:65233-2874
Practice Address - Country:US
Practice Address - Phone:573-540-7160
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-12-01
Last Update Date:2023-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOS081081006172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver