Provider Demographics
NPI:1861893737
Name:WHITE, CHANCE ERIC (DPT)
Entity type:Individual
Prefix:
First Name:CHANCE
Middle Name:ERIC
Last Name:WHITE
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 68
Mailing Address - Street 2:
Mailing Address - City:CHAFFEE
Mailing Address - State:MO
Mailing Address - Zip Code:63740-0068
Mailing Address - Country:US
Mailing Address - Phone:573-887-3615
Mailing Address - Fax:
Practice Address - Street 1:407 E PARKER AVE
Practice Address - Street 2:
Practice Address - City:CHAFFEE
Practice Address - State:MO
Practice Address - Zip Code:63740-1030
Practice Address - Country:US
Practice Address - Phone:573-450-7398
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-09-10
Last Update Date:2014-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2014023115225100000X
KS11-04863225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist