Provider Demographics
NPI:1134603129
Name:CHANCELLOR, TODD
Entity type:Individual
Prefix:
First Name:TODD
Middle Name:
Last Name:CHANCELLOR
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 1:13052 COMPTON RD
Mailing Address - Street 2:
Mailing Address - City:LOXAHATCHEE
Mailing Address - State:FL
Mailing Address - Zip Code:33470-4714
Mailing Address - Country:US
Mailing Address - Phone:561-797-7203
Mailing Address - Fax:561-795-3014
Practice Address - Street 1:808 S BROADWAY
Practice Address - Street 2:
Practice Address - City:LANTANA
Practice Address - State:FL
Practice Address - Zip Code:33462-4400
Practice Address - Country:US
Practice Address - Phone:561-797-7203
Practice Address - Fax:561-797-3014
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-17
Last Update Date:2020-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
310400000X
FLAL12699310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL105771000Medicaid