Provider Demographics
NPI:1720771199
Name:MIZELL, CHANCE M
Entity Type:Individual
Prefix:
First Name:CHANCE
Middle Name:M
Last Name:MIZELL
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 1:12527 N COTTONSEED LN
Mailing Address - Street 2:
Mailing Address - City:MARANA
Mailing Address - State:AZ
Mailing Address - Zip Code:85653-8228
Mailing Address - Country:US
Mailing Address - Phone:575-650-1371
Mailing Address - Fax:
Practice Address - Street 1:7635 N LA CHOLLA BLVD
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85741-4202
Practice Address - Country:US
Practice Address - Phone:520-297-2704
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-31
Last Update Date:2023-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLDO002710156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician