Provider Demographics
NPI:1063399020
Name:BUSH, CHANCELOR
Entity type:Individual
Prefix:
First Name:CHANCELOR
Middle Name:
Last Name:BUSH
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 1:1720 FREDERICK AVE SW
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:OH
Mailing Address - Zip Code:44706-5314
Mailing Address - Country:US
Mailing Address - Phone:330-224-4823
Mailing Address - Fax:330-224-4823
Practice Address - Street 1:108 3RD ST NE
Practice Address - Street 2:
Practice Address - City:MASSILLON
Practice Address - State:OH
Practice Address - Zip Code:44646-5605
Practice Address - Country:US
Practice Address - Phone:330-224-4823
Practice Address - Fax:614-468-1246
Is Sole Proprietor?:Yes
Enumeration Date:2025-08-20
Last Update Date:2025-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH7611206374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH853687387Medicaid