Provider Demographics
NPI:1467160218
Name:CHRISTIAN, CHARLES
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:
Last Name:CHRISTIAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:92 BRADFORD ST APT 4
Mailing Address - Street 2:
Mailing Address - City:FORT WALTON BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32547-1943
Mailing Address - Country:US
Mailing Address - Phone:706-681-3684
Mailing Address - Fax:
Practice Address - Street 1:108 WAGNER RD
Practice Address - Street 2:
Practice Address - City:BONIFAY
Practice Address - State:FL
Practice Address - Zip Code:32425-2923
Practice Address - Country:US
Practice Address - Phone:706-681-3684
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-11-10
Last Update Date:2022-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376G00000XNursing Service Related ProvidersNursing Home Administrator