Provider Demographics
NPI:1285822528
Name:MURDOCK, CHAUNCEY L (LVN)
Entity Type:Individual
Prefix:
First Name:CHAUNCEY
Middle Name:L
Last Name:MURDOCK
Suffix:
Gender:M
Credentials:LVN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1101 FLORIDA ST
Mailing Address - Street 2:
Mailing Address - City:IMPERIAL BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:91932-2907
Mailing Address - Country:US
Mailing Address - Phone:619-423-3295
Mailing Address - Fax:
Practice Address - Street 1:1101 FLORIDA ST
Practice Address - Street 2:
Practice Address - City:IMPERIAL BEACH
Practice Address - State:CA
Practice Address - Zip Code:91932-2907
Practice Address - Country:US
Practice Address - Phone:619-423-3295
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-11
Last Update Date:2007-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA209265164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
CARVN004450Medicaid