Provider Demographics
NPI:1336690189
Name:EDWARDS, CHARLES FREEMEN
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:FREEMEN
Last Name:EDWARDS
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 1:3910 SE STARK ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97214-3241
Mailing Address - Country:US
Mailing Address - Phone:503-235-8655
Mailing Address - Fax:503-802-0598
Practice Address - Street 1:537 SE ALDER ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97214-2231
Practice Address - Country:US
Practice Address - Phone:503-595-3477
Practice Address - Fax:503-595-3478
Is Sole Proprietor?:No
Enumeration Date:2016-10-17
Last Update Date:2017-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR16-CRM-179175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist