Provider Demographics
NPI:1083376859
Name:MATHEWS, CHARLES EDWARD III
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:EDWARD
Last Name:MATHEWS
Suffix:III
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4811 E SAM HOUSTON PKWY S APT 622
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:TX
Mailing Address - Zip Code:77505-3985
Mailing Address - Country:US
Mailing Address - Phone:832-477-0117
Mailing Address - Fax:
Practice Address - Street 1:4811 E SAM HOUSTON PKWY S APT 622
Practice Address - Street 2:
Practice Address - City:PASADENA
Practice Address - State:TX
Practice Address - Zip Code:77505-3985
Practice Address - Country:US
Practice Address - Phone:832-477-0117
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-08
Last Update Date:2021-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX108683225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist