Provider Demographics
NPI:1871043141
Name:MCINTOSH, CHANDRA LAVARRE
Entity Type:Individual
Prefix:
First Name:CHANDRA
Middle Name:LAVARRE
Last Name:MCINTOSH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18028 FREELAND ST
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48235-2571
Mailing Address - Country:US
Mailing Address - Phone:313-680-4130
Mailing Address - Fax:
Practice Address - Street 1:18028 FREELAND ST
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48235-2571
Practice Address - Country:US
Practice Address - Phone:313-680-4130
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-10-10
Last Update Date:2016-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI247200000XOtherTECHNICIAN