Provider Demographics
NPI:1164006763
Name:BOLLACKER, CHARLES (PTA)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:
Last Name:BOLLACKER
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1635 NEEDY RD
Mailing Address - Street 2:
Mailing Address - City:MARTINSBURG
Mailing Address - State:WV
Mailing Address - Zip Code:25405-6200
Mailing Address - Country:US
Mailing Address - Phone:304-620-2034
Mailing Address - Fax:
Practice Address - Street 1:11110 MEDICAL CAMPUS RD STE 101
Practice Address - Street 2:
Practice Address - City:HAGERSTOWN
Practice Address - State:MD
Practice Address - Zip Code:21742-6711
Practice Address - Country:US
Practice Address - Phone:301-665-4970
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-10
Last Update Date:2021-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant