Provider Demographics
NPI:1164936878
Name:BALENTINE, CHARLES ELLIS
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:ELLIS
Last Name:BALENTINE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 HIGGINSON PL N
Mailing Address - Street 2:
Mailing Address - City:GALLATIN
Mailing Address - State:TN
Mailing Address - Zip Code:37066-6086
Mailing Address - Country:US
Mailing Address - Phone:615-521-4380
Mailing Address - Fax:
Practice Address - Street 1:315 DEADERICK ST STE 1550
Practice Address - Street 2:
Practice Address - City:NASHVILLE
Practice Address - State:TN
Practice Address - Zip Code:37238-3003
Practice Address - Country:US
Practice Address - Phone:615-521-4380
Practice Address - Fax:615-521-4380
Is Sole Proprietor?:No
Enumeration Date:2017-11-17
Last Update Date:2017-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN44D2125377246QL0900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246QL0900XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, PathologyLaboratory Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN44D2125377OtherLICENSURE/LAB (CMS)