Provider Demographics
NPI:1568047074
Name:STACKPOLE, CHAD
Entity Type:Individual
Prefix:
First Name:CHAD
Middle Name:
Last Name:STACKPOLE
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 1:367 YOUNG HOLLOW RD
Mailing Address - Street 2:
Mailing Address - City:FOLSOM
Mailing Address - State:WV
Mailing Address - Zip Code:26348-6044
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:367 YOUNG HOLLOW RD
Practice Address - Street 2:
Practice Address - City:FOLSOM
Practice Address - State:WV
Practice Address - Zip Code:26348-6044
Practice Address - Country:US
Practice Address - Phone:304-334-6361
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-16
Last Update Date:2021-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker