1841408713 NPI number — MELODY A CHARLESON OTR-L

Table of content: KITTU JINDAL GARG M.D. (NPI 1629395322)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1841408713 NPI number — MELODY A CHARLESON OTR-L

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CHARLESON
Provider First Name:
MELODY
Provider Middle Name:
A
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
OTR-L
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1841408713
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/24/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
12164 LOWELL CIR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
COUNCIL BLUFFS
Provider Business Mailing Address State Name:
IA
Provider Business Mailing Address Postal Code:
51503-7080
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
712-328-1970
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8031 W CENTER RD
Provider Second Line Business Practice Location Address:
SUITE 225
Provider Business Practice Location Address City Name:
OMAHA
Provider Business Practice Location Address State Name:
NE
Provider Business Practice Location Address Postal Code:
68124-3158
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
402-391-5002
Provider Business Practice Location Address Fax Number:
402-343-1278
Provider Enumeration Date:
05/21/2007

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: 225X00000X , with the licence number:  409 , registered in the state of NE ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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