Provider Demographics
NPI:1093137143
Name:BRIDGES, CHARLES IV
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:
Last Name:BRIDGES
Suffix:IV
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 1:111 MIDLAND CT
Mailing Address - Street 2:
Mailing Address - City:NICEVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32578-9765
Mailing Address - Country:US
Mailing Address - Phone:850-499-2930
Mailing Address - Fax:850-897-0372
Practice Address - Street 1:111 MIDLAND CT
Practice Address - Street 2:
Practice Address - City:NICEVILLE
Practice Address - State:FL
Practice Address - Zip Code:32578-9765
Practice Address - Country:US
Practice Address - Phone:850-499-2930
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-01-08
Last Update Date:2014-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLW019590174H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174H00000XOther Service ProvidersHealth Educator