Provider Demographics
NPI:1275502197
Name:PAYNE, CHARLES FREDERICK (PT)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:FREDERICK
Last Name:PAYNE
Suffix:
Gender:M
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:PO BOX 398
Mailing Address - Street 2:
Mailing Address - City:AMITE
Mailing Address - State:LA
Mailing Address - Zip Code:70422-0398
Mailing Address - Country:US
Mailing Address - Phone:985-748-7878
Mailing Address - Fax:
Practice Address - Street 1:216 NORTH SECOND ST
Practice Address - Street 2:
Practice Address - City:AMITE
Practice Address - State:LA
Practice Address - Zip Code:70422-0398
Practice Address - Country:US
Practice Address - Phone:985-748-7878
Practice Address - Fax:985-748-2837
Is Sole Proprietor?:No
Enumeration Date:2006-03-14
Last Update Date:2007-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA1013225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1986186Medicaid
LA1986186Medicaid