Provider Demographics
NPI:1255994836
Name:PACK, KOLEY CHANCE
Entity type:Individual
Prefix:
First Name:KOLEY
Middle Name:CHANCE
Last Name:PACK
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 1:2001 S COULTER ST
Mailing Address - Street 2:
Mailing Address - City:AMARILLO
Mailing Address - State:TX
Mailing Address - Zip Code:79106-2521
Mailing Address - Country:US
Mailing Address - Phone:806-318-5777
Mailing Address - Fax:806-513-6926
Practice Address - Street 1:2001 S COULTER ST
Practice Address - Street 2:
Practice Address - City:AMARILLO
Practice Address - State:TX
Practice Address - Zip Code:79106-2521
Practice Address - Country:US
Practice Address - Phone:806-318-5777
Practice Address - Fax:806-513-6926
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-18
Last Update Date:2022-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXT8007207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine