Provider Demographics
NPI:1356813059
Name:ILLINGWORTH, CHARLES BLAINE IV (DIPLAC, LAC)
Entity Type:Individual
Prefix:MR
First Name:CHARLES
Middle Name:BLAINE
Last Name:ILLINGWORTH
Suffix:IV
Gender:M
Credentials:DIPLAC, LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4476 FLEMING ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19128-4809
Mailing Address - Country:US
Mailing Address - Phone:610-724-3284
Mailing Address - Fax:
Practice Address - Street 1:601 E MAIN ST
Practice Address - Street 2:
Practice Address - City:LANSDALE
Practice Address - State:PA
Practice Address - Zip Code:19446-2947
Practice Address - Country:US
Practice Address - Phone:610-724-3284
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-19
Last Update Date:2018-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAAK001285171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171100000XOther Service ProvidersAcupuncturistGroup - Single Specialty