1528196706 NPI number — MR. CHARLES ASHLEY EIDSON PT, MS

Table of content: MR. CHARLES ASHLEY EIDSON PT, MS (NPI 1528196706)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1528196706 NPI number — MR. CHARLES ASHLEY EIDSON PT, MS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
EIDSON
Provider First Name:
CHARLES
Provider Middle Name:
ASHLEY
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
PT, MS
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
EIDSON
Provider Other First Name:
CHUCK
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
PT, MS
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1528196706
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/09/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 368
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PECOS
Provider Business Mailing Address State Name:
NM
Provider Business Mailing Address Postal Code:
87552-0368
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
505-757-4644
Provider Business Mailing Address Fax Number:
505-757-3049

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
PECOS SCHOOLS HWY 63
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PECOS
Provider Business Practice Location Address State Name:
NM
Provider Business Practice Location Address Postal Code:
87552-0368
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
505-757-4644
Provider Business Practice Location Address Fax Number:
505-757-3049
Provider Enumeration Date:
03/01/2007

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , with the licence number:  1322 , registered in the state of NM ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 000R7048 , issued by the state of ( NM ) . This identifiers is of the category "MEDICAID".