Provider Demographics
NPI:1609513522
Name:CHICOINE, CONNER HART
Entity Type:Individual
Prefix:
First Name:CONNER
Middle Name:HART
Last Name:CHICOINE
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 1:1152 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:LAKEPORT
Mailing Address - State:CA
Mailing Address - Zip Code:95453-5517
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6945 OLD HIGHWAY 53
Practice Address - Street 2:
Practice Address - City:CLEARLAKE
Practice Address - State:CA
Practice Address - Zip Code:95422-9381
Practice Address - Country:US
Practice Address - Phone:707-995-9523
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-13
Last Update Date:2022-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator