Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 111NN1001X | Nutrition | DC001275L | PA |
NPI | 1558410043 |
---|---|
Provider Name | Dr. Clarence Charles Chase JR. |
First Address | Erie, PA 16509-4722 |
Second Address | Erie, PA 16509-4722 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 10/01/2007 |
Last Update Date | 10/05/2017 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
115966 | (02) | PA |