Provider Demographics
NPI:1114623295
Name:WATTERS, CHARLES
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:
Last Name:WATTERS
Suffix:
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 1:3 E SHORE BLVD
Mailing Address - Street 2:
Mailing Address - City:TIMBERLAKE
Mailing Address - State:OH
Mailing Address - Zip Code:44095-1901
Mailing Address - Country:US
Mailing Address - Phone:440-865-1087
Mailing Address - Fax:
Practice Address - Street 1:3 E SHORE BLVD
Practice Address - Street 2:
Practice Address - City:TIMBERLAKE
Practice Address - State:OH
Practice Address - Zip Code:44095-1901
Practice Address - Country:US
Practice Address - Phone:440-865-1087
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-01
Last Update Date:2023-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant