Provider Demographics
NPI:1053443267
Name:BUNTON, CHARLES EDWARD JR (MA, ATC, LAT)
Entity Type:Individual
Prefix:MR
First Name:CHARLES
Middle Name:EDWARD
Last Name:BUNTON
Suffix:JR
Gender:M
Credentials:MA, ATC, LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4811 KELLY RD
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33615-5020
Mailing Address - Country:US
Mailing Address - Phone:813-885-1673
Mailing Address - Fax:813-243-8453
Practice Address - Street 1:4811 KELLY RD
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33615-5020
Practice Address - Country:US
Practice Address - Phone:813-885-1673
Practice Address - Fax:813-243-8453
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL8452255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer