Provider Demographics
NPI:1407048903
Name:NIESEN, CHARLES WALLACE III (LMP)
Entity Type:Individual
Prefix:MR
First Name:CHARLES
Middle Name:WALLACE
Last Name:NIESEN
Suffix:III
Gender:M
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 252
Mailing Address - Street 2:
Mailing Address - City:BELFAIR
Mailing Address - State:WA
Mailing Address - Zip Code:98528-0252
Mailing Address - Country:US
Mailing Address - Phone:360-801-1295
Mailing Address - Fax:
Practice Address - Street 1:7950 STATE HIGHWAY 3 SW
Practice Address - Street 2:
Practice Address - City:PORT ORCHARD
Practice Address - State:WA
Practice Address - Zip Code:98367-9149
Practice Address - Country:US
Practice Address - Phone:360-801-1295
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-17
Last Update Date:2007-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00018507225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist