Provider Demographics
NPI:1154503605
Name:CHARLES A WARDLE
Entity Type:Organization
Organization Name:CHARLES A WARDLE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:DARCY
Authorized Official - Middle Name:
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:LDO
Authorized Official - Phone:360-423-7650
Mailing Address - Street 1:PO BOX 928
Mailing Address - Street 2:
Mailing Address - City:LONGVIEW
Mailing Address - State:WA
Mailing Address - Zip Code:98632-7582
Mailing Address - Country:US
Mailing Address - Phone:360-423-7650
Mailing Address - Fax:360-423-2346
Practice Address - Street 1:1426 COMMERCE AVE
Practice Address - Street 2:
Practice Address - City:LONGVIEW
Practice Address - State:WA
Practice Address - Zip Code:98632-3720
Practice Address - Country:US
Practice Address - Phone:360-423-7650
Practice Address - Fax:360-423-2346
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-27
Last Update Date:2010-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA907152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WADG6451OtherRAILROAD MEDICARE
WA2046902Medicaid
WAT02612Medicare UPIN
WA2046902Medicaid
WA0765050001Medicare NSC