Provider Demographics
NPI:1033642350
Name:HEWETT, CHARLES EUGENE III (ATC, LAT)
Entity Type:Individual
Prefix:MR
First Name:CHARLES
Middle Name:EUGENE
Last Name:HEWETT
Suffix:III
Gender:M
Credentials:ATC, LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:131 CONQUEST AVE
Mailing Address - Street 2:
Mailing Address - City:CRESTVIEW
Mailing Address - State:FL
Mailing Address - Zip Code:32536-6525
Mailing Address - Country:US
Mailing Address - Phone:850-902-6826
Mailing Address - Fax:
Practice Address - Street 1:550 REDSTONE AVE W
Practice Address - Street 2:
Practice Address - City:CRESTVIEW
Practice Address - State:FL
Practice Address - Zip Code:32536-6428
Practice Address - Country:US
Practice Address - Phone:850-683-5906
Practice Address - Fax:850-683-5917
Is Sole Proprietor?:No
Enumeration Date:2017-04-04
Last Update Date:2017-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL30852255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer