Provider Demographics
NPI:1407624166
Name:CHARLEY, DESIE
Entity Type:Individual
Prefix:
First Name:DESIE
Middle Name:
Last Name:CHARLEY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 GOLD FLOWER TRL
Mailing Address - Street 2:
Mailing Address - City:ST MATTHEWS
Mailing Address - State:SC
Mailing Address - Zip Code:29135-7743
Mailing Address - Country:US
Mailing Address - Phone:803-413-6876
Mailing Address - Fax:
Practice Address - Street 1:101 GOLD FLOWER TRL
Practice Address - Street 2:
Practice Address - City:ST MATTHEWS
Practice Address - State:SC
Practice Address - Zip Code:29135-7743
Practice Address - Country:US
Practice Address - Phone:803-413-6876
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-12-12
Last Update Date:2023-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC007939270347C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes347C00000XTransportation ServicesPrivate Vehicle