Provider Demographics
NPI:1245747906
Name:CHANCELLOR, WILLIAM WADE (LDO,ABOC,NCLEC)
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:WADE
Last Name:CHANCELLOR
Suffix:
Gender:M
Credentials:LDO,ABOC,NCLEC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9 N LEE ST
Mailing Address - Street 2:
Mailing Address - City:FORSYTH
Mailing Address - State:GA
Mailing Address - Zip Code:31029-2114
Mailing Address - Country:US
Mailing Address - Phone:478-258-3838
Mailing Address - Fax:478-993-0344
Practice Address - Street 1:9 N LEE ST
Practice Address - Street 2:
Practice Address - City:FORSYTH
Practice Address - State:GA
Practice Address - Zip Code:31029-2114
Practice Address - Country:US
Practice Address - Phone:478-258-3838
Practice Address - Fax:478-993-0344
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-03
Last Update Date:2021-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALDO0002590156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
Provider Identifiers
StateIdentifier IDID TypeIssuer
GALDO002590OtherLICENSED DISPENSING OPTICIAN