Provider Demographics
NPI:1205214616
Name:BARNETT, CHARLES DEWAYNE
Entity Type:Individual
Prefix:MR
First Name:CHARLES
Middle Name:DEWAYNE
Last Name:BARNETT
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 1:407 N 2ND ST
Mailing Address - Street 2:
Mailing Address - City:THAYER
Mailing Address - State:MO
Mailing Address - Zip Code:65791-1123
Mailing Address - Country:US
Mailing Address - Phone:870-805-1286
Mailing Address - Fax:
Practice Address - Street 1:1015 LANTON RD
Practice Address - Street 2:
Practice Address - City:WEST PLAINS
Practice Address - State:MO
Practice Address - Zip Code:65775-3854
Practice Address - Country:US
Practice Address - Phone:417-256-2570
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-05-18
Last Update Date:2016-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR160759724Medicaid