Provider Demographics
NPI:1164066189
Name:WENGER, CHARLES LORELL (ATC)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:LORELL
Last Name:WENGER
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:269 GOBBLER DR
Mailing Address - Street 2:
Mailing Address - City:BROADWAY
Mailing Address - State:VA
Mailing Address - Zip Code:22815-9483
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:269 GOBBLER DR
Practice Address - Street 2:
Practice Address - City:BROADWAY
Practice Address - State:VA
Practice Address - Zip Code:22815-9483
Practice Address - Country:US
Practice Address - Phone:540-896-7081
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-11-02
Last Update Date:2019-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA01260012122255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer