Provider Demographics
NPI:1164417895
Name:BOARDMAN, CHARLES HOLLOWAY IV (OTR)
Entity Type:Individual
Prefix:MR
First Name:CHARLES
Middle Name:HOLLOWAY
Last Name:BOARDMAN
Suffix:IV
Gender:M
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:355 SW SWEETBREEZE DR
Mailing Address - Street 2:
Mailing Address - City:LAKE CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32024-3698
Mailing Address - Country:US
Mailing Address - Phone:386-755-3016
Mailing Address - Fax:
Practice Address - Street 1:619 SOUTH MARION AVE
Practice Address - Street 2:NORTH FLORIDA / SOUTH GEORGIA VETERANS HEALTH SYSTEM
Practice Address - City:LAKE CITY
Practice Address - State:FL
Practice Address - Zip Code:32025
Practice Address - Country:US
Practice Address - Phone:386-755-3016
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-09-19
Last Update Date:2012-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOT14416FL225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLOT14416FLOtherFLORIDA DEPARTMENT OF HEALTH
AA499343OtherNBCOT