Provider Demographics
NPI:1164552337
Name:SWAIN, CHARLENE VANDRIL (PT)
Entity Type:Individual
Prefix:MRS
First Name:CHARLENE
Middle Name:VANDRIL
Last Name:SWAIN
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:73 S LAKE DOSTER DR
Mailing Address - Street 2:
Mailing Address - City:PLAINWELL
Mailing Address - State:MI
Mailing Address - Zip Code:49080-9109
Mailing Address - Country:US
Mailing Address - Phone:269-664-4022
Mailing Address - Fax:
Practice Address - Street 1:8450 N 43RD ST
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:MI
Practice Address - Zip Code:49012-9651
Practice Address - Country:US
Practice Address - Phone:269-731-4471
Practice Address - Fax:269-731-2990
Is Sole Proprietor?:No
Enumeration Date:2007-03-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501005239225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist