Individual
CHANCE RAY SHADWICK
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Contact information
Practice address
405 E EXCELSIOR AVE, VINITA, OK 74301-4226
(918) 864-0706
Mailing address
405 E EXCELSIOR AVE, VINITA, OK 74301-4226
Taxonomy
Speciality
Code
Description
License number
State
175T00000X
Peer Specialist
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
1710994835
—
OK
Enumeration date
02/15/2023
Last updated
02/15/2023
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