Provider Demographics
NPI:1427198449
Name:CHANDLER FAMILY PRACTICE, PC
Entity Type:Organization
Organization Name:CHANDLER FAMILY PRACTICE, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE ADMIN.
Authorized Official - Prefix:MRS
Authorized Official - First Name:MARY
Authorized Official - Middle Name:L
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:480-963-9334
Mailing Address - Street 1:1076 W CHANDLER BLVD
Mailing Address - Street 2:SUITE 113
Mailing Address - City:CHANDLER
Mailing Address - State:AZ
Mailing Address - Zip Code:85224-5225
Mailing Address - Country:US
Mailing Address - Phone:480-963-9334
Mailing Address - Fax:480-963-0444
Practice Address - Street 1:1076 W CHANDLER BLVD
Practice Address - Street 2:SUITE 113
Practice Address - City:CHANDLER
Practice Address - State:AZ
Practice Address - Zip Code:85224-5225
Practice Address - Country:US
Practice Address - Phone:480-963-9334
Practice Address - Fax:480-963-0444
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-07
Last Update Date:2008-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ13278261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ251166Medicaid
AZZWMBMPMedicare ID - Type Unspecified
AZD37851Medicare UPIN