Provider Demographics
NPI:1437257540
Name:ANDERSON, CHARLES L (BC-HIS)
Entity Type:Individual
Prefix:MR
First Name:CHARLES
Middle Name:L
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:BC-HIS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:230 S GRANT ST
Mailing Address - Street 2:
Mailing Address - City:FAIRMONT
Mailing Address - State:MN
Mailing Address - Zip Code:56031-3936
Mailing Address - Country:US
Mailing Address - Phone:507-235-5323
Mailing Address - Fax:
Practice Address - Street 1:230 S GRANT ST
Practice Address - Street 2:
Practice Address - City:FAIRMONT
Practice Address - State:MN
Practice Address - Zip Code:56031-3936
Practice Address - Country:US
Practice Address - Phone:507-235-5323
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2080237700000X
IA00487237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist