Provider Demographics
NPI:1568243855
Name:THOMAS, CHANDLER DEJUAN
Entity Type:Individual
Prefix:
First Name:CHANDLER
Middle Name:DEJUAN
Last Name:THOMAS
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 1:9041 CATTARAUGUS AVE
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90034-1920
Mailing Address - Country:US
Mailing Address - Phone:317-496-9028
Mailing Address - Fax:
Practice Address - Street 1:9041 CATTARAUGUS AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90034-1920
Practice Address - Country:US
Practice Address - Phone:317-496-9028
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-10-11
Last Update Date:2023-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA8GQE116172A00000X
343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)
No172A00000XOther Service ProvidersDriver