Provider Demographics
NPI:1043236714
Name:TYNER, CHARLES THOMAS (MPT)
Entity Type:Individual
Prefix:MR
First Name:CHARLES
Middle Name:THOMAS
Last Name:TYNER
Suffix:
Gender:M
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7133 EDGEWATER DR
Mailing Address - Street 2:
Mailing Address - City:MANDEVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:70471-7431
Mailing Address - Country:US
Mailing Address - Phone:985-653-9242
Mailing Address - Fax:985-653-9324
Practice Address - Street 1:301 W AIRLINE HWY
Practice Address - Street 2:SUITE 104
Practice Address - City:LA PLACE
Practice Address - State:LA
Practice Address - Zip Code:70068-3823
Practice Address - Country:US
Practice Address - Phone:985-653-9242
Practice Address - Fax:985-653-9324
Is Sole Proprietor?:No
Enumeration Date:2006-07-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LALA4433225100000X, 2251S0007X, 2251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Not Answered2251S0007XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistSports
Not Answered2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA4H491CQ30Medicare ID - Type UnspecifiedMEDICARE PROVIDER #