Provider Demographics
NPI:1366006728
Name:AGBONGHAE, CHARLES (PT)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:
Last Name:AGBONGHAE
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 1:10021 BIRCH TREE DR
Mailing Address - Street 2:
Mailing Address - City:TEMPLE
Mailing Address - State:TX
Mailing Address - Zip Code:76502-5368
Mailing Address - Country:US
Mailing Address - Phone:254-421-9364
Mailing Address - Fax:
Practice Address - Street 1:4800 MEMORIAL DR
Practice Address - Street 2:
Practice Address - City:WACO
Practice Address - State:TX
Practice Address - Zip Code:76711-1329
Practice Address - Country:US
Practice Address - Phone:254-421-9364
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-30
Last Update Date:2019-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1203007225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist