Provider Demographics
NPI:1477184588
Name:HARTLEY, CHARLES GREGORY II
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:GREGORY
Last Name:HARTLEY
Suffix:II
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 1:4315 GOLF CLUB DR APT 7012
Mailing Address - Street 2:
Mailing Address - City:AUBURN
Mailing Address - State:AL
Mailing Address - Zip Code:36830-5981
Mailing Address - Country:US
Mailing Address - Phone:205-834-0051
Mailing Address - Fax:
Practice Address - Street 1:4315 GOLF CLUB DR APT 7012
Practice Address - Street 2:
Practice Address - City:AUBURN
Practice Address - State:AL
Practice Address - Zip Code:36830-5981
Practice Address - Country:US
Practice Address - Phone:205-834-0051
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-28
Last Update Date:2020-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALS12676390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program