Provider Demographics
NPI:1801674361
Name:RYAN, CHANCE GAUGE (LMBT)
Entity type:Individual
Prefix:
First Name:CHANCE
Middle Name:GAUGE
Last Name:RYAN
Suffix:
Gender:M
Credentials:LMBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5811 MARKET WAY DR APT 3104
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28277-4936
Mailing Address - Country:US
Mailing Address - Phone:970-734-3094
Mailing Address - Fax:
Practice Address - Street 1:9905 SANDY ROCK PL STE B&D
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28277-7734
Practice Address - Country:US
Practice Address - Phone:704-541-2600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-09-18
Last Update Date:2023-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO15659225700000X
TX135843225700000X
NC07961225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist