Provider Demographics
NPI:1326699570
Name:SMALLS, CHARLES E
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:E
Last Name:SMALLS
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 1:565 MATIANUCK AVE
Mailing Address - Street 2:
Mailing Address - City:WINDSOR
Mailing Address - State:CT
Mailing Address - Zip Code:06095-3512
Mailing Address - Country:US
Mailing Address - Phone:860-967-1511
Mailing Address - Fax:860-219-9514
Practice Address - Street 1:565 MATIANUCK AVE
Practice Address - Street 2:
Practice Address - City:WINDSOR
Practice Address - State:CT
Practice Address - Zip Code:06095-3512
Practice Address - Country:US
Practice Address - Phone:860-967-1511
Practice Address - Fax:860-219-9514
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-27
Last Update Date:2019-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747A0650XNursing Service Related ProvidersTechnicianAttendant Care Provider