Provider Demographics
NPI:1376068866
Name:MACK, CHARLES EDWARD JR (DPT)
Entity Type:Individual
Prefix:MR
First Name:CHARLES
Middle Name:EDWARD
Last Name:MACK
Suffix:JR
Gender:M
Credentials:DPT
Other - Prefix:
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Mailing Address - Street 1:19490 SANDRIDGE WAY STE 170
Mailing Address - Street 2:
Mailing Address - City:LANSDOWNE
Mailing Address - State:VA
Mailing Address - Zip Code:20176-3467
Mailing Address - Country:US
Mailing Address - Phone:703-723-4088
Mailing Address - Fax:
Practice Address - Street 1:19490 SANDRIDGE WAY STE 170
Practice Address - Street 2:
Practice Address - City:LANSDOWNE
Practice Address - State:VA
Practice Address - Zip Code:20176-3467
Practice Address - Country:US
Practice Address - Phone:703-723-4088
Practice Address - Fax:703-723-4088
Is Sole Proprietor?:No
Enumeration Date:2017-08-07
Last Update Date:2017-08-07
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
VA2305211409225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist