Provider Demographics
NPI:1194840835
Name:CHARLES, FORREST L
Entity Type:Individual
Prefix:
First Name:FORREST
Middle Name:L
Last Name:CHARLES
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 1:10703 S OLD GLENN HWY
Mailing Address - Street 2:
Mailing Address - City:PALMER
Mailing Address - State:AK
Mailing Address - Zip Code:99645-8228
Mailing Address - Country:US
Mailing Address - Phone:907-745-5715
Mailing Address - Fax:907-745-0518
Practice Address - Street 1:10703 S OLD GLENN HWY
Practice Address - Street 2:
Practice Address - City:PALMER
Practice Address - State:AK
Practice Address - Zip Code:99645-8228
Practice Address - Country:US
Practice Address - Phone:907-745-5715
Practice Address - Fax:907-745-0518
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK232050310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKRL7474Medicaid