Provider Demographics
NPI:1679337885
Name:REVEAL, CHASE
Entity type:Individual
Prefix:
First Name:CHASE
Middle Name:
Last Name:REVEAL
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 1:521 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WEST LAFAYETTE
Mailing Address - State:OH
Mailing Address - Zip Code:43845-1221
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:521 E MAIN ST
Practice Address - Street 2:
Practice Address - City:WEST LAFAYETTE
Practice Address - State:OH
Practice Address - Zip Code:43845-1221
Practice Address - Country:US
Practice Address - Phone:740-610-7446
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-02-08
Last Update Date:2024-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHTZ934270172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver