1316453384 NPI number — CHARLES WADE WEAVER ATC, AT, LAT

Table of content: CHARLES WADE WEAVER ATC, AT, LAT (NPI 1316453384)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1316453384 NPI number — CHARLES WADE WEAVER ATC, AT, LAT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WEAVER
Provider First Name:
CHARLES
Provider Middle Name:
WADE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
ATC, AT, LAT
Provider Gender Code:
M

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:
1316453384
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/28/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
11399 DAVIS RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MIDDLEVILLE
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
49333-8652
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
11399 DAVIS RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MIDDLEVILLE
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
49333-8652
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
936-443-6289
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
12/28/2017

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: 2255A2300X , with the licence number:  2000008006 ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 2601001771 . This is a "ATHLETIC TRAINER LICENSE" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: AT2652 . This is a "LICENSED ATHLETIC TRAINER" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 2000008006 . This is a "ATHLETIC TRAINING CERTIFICATION, BOC" identifier . This identifiers is of the category "OTHER".




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