Provider Demographics
NPI:1780665737
Name:CHANEY, MARK DAVID
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:DAVID
Last Name:CHANEY
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 1:4012 GROVER ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83705-1428
Mailing Address - Country:US
Mailing Address - Phone:208-345-7742
Mailing Address - Fax:208-345-7742
Practice Address - Street 1:4012 GROVER ST
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83705-1428
Practice Address - Country:US
Practice Address - Phone:208-345-7742
Practice Address - Fax:208-345-7742
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-11-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes132700000XDietary & Nutritional Service ProvidersDietary Manager