Provider Demographics
NPI:1609972702
Name:WUNDERLICH, CHANCE A (DC)
Entity Type:Individual
Prefix:
First Name:CHANCE
Middle Name:A
Last Name:WUNDERLICH
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1402 LAFAYETTE ST
Mailing Address - Street 2:
Mailing Address - City:CAPE CORAL
Mailing Address - State:FL
Mailing Address - Zip Code:33904-9763
Mailing Address - Country:US
Mailing Address - Phone:239-540-9888
Mailing Address - Fax:239-540-9889
Practice Address - Street 1:1402 LAFAYETTE ST
Practice Address - Street 2:
Practice Address - City:CAPE CORAL
Practice Address - State:FL
Practice Address - Zip Code:33904-9763
Practice Address - Country:US
Practice Address - Phone:239-540-9888
Practice Address - Fax:239-540-9889
Is Sole Proprietor?:No
Enumeration Date:2006-09-15
Last Update Date:2008-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH7090111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL55416OtherBCBS ID #
FLCH7090OtherSTATE LICENSE
FLCH7090OtherSTATE LICENSE
FL55461ZMedicare PIN