1750304598 NPI number — CHARLES CLARKE TANNER MPT, COMT, ATC, CSCS

Table of content: CHARLES CLARKE TANNER MPT, COMT, ATC, CSCS (NPI 1750304598)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1750304598 NPI number — CHARLES CLARKE TANNER MPT, COMT, ATC, CSCS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
TANNER
Provider First Name:
CHARLES
Provider Middle Name:
CLARKE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MPT, COMT, ATC, CSCS
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:
1750304598
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/04/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7400 BEAUFONT SPRINGS DR
Provider Second Line Business Mailing Address:
SUITE 120
Provider Business Mailing Address City Name:
RICHMOND
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
23225-5556
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
804-320-2220
Provider Business Mailing Address Fax Number:
804-320-2226

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7400 BEAUFONT SPRINGS DR
Provider Second Line Business Practice Location Address:
SUITE 120
Provider Business Practice Location Address City Name:
RICHMOND
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
23225-5556
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
804-320-2220
Provider Business Practice Location Address Fax Number:
804-320-2226
Provider Enumeration Date:
07/25/2006

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: 2251X0800X , with the licence number:  2305202905 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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