1386198604 NPI number — CHARLES MCKNIGHT LCDC

Table of content: CHARLES MCKNIGHT LCDC (NPI 1386198604)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1386198604 NPI number — CHARLES MCKNIGHT LCDC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MCKNIGHT
Provider First Name:
CHARLES
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LCDC
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
MCKNIGHT
Provider Other First Name:
CHARLES
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
LCDC
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1386198604
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/04/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
322 MONTAGUE AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAN ANGELO
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
76905-5110
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
325-224-3481
Provider Business Mailing Address Fax Number:
325-224-4923

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3553 W HOUSTON HARTE EXPY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SAN ANGELO
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
76901-2664
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
325-224-3481
Provider Business Practice Location Address Fax Number:
325-224-4923
Provider Enumeration Date:
08/04/2016

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: 101YA0400X , with the licence number:  13489 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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