Provider Demographics
NPI:1528196706
Name:EIDSON, CHARLES ASHLEY (PT, MS)
Entity Type:Individual
Prefix:MR
First Name:CHARLES
Middle Name:ASHLEY
Last Name:EIDSON
Suffix:
Gender:M
Credentials:PT, MS
Other - Prefix:
Other - First Name:CHUCK
Other - Middle Name:
Other - Last Name:EIDSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PT, MS
Mailing Address - Street 1:PO BOX 368
Mailing Address - Street 2:
Mailing Address - City:PECOS
Mailing Address - State:NM
Mailing Address - Zip Code:87552-0368
Mailing Address - Country:US
Mailing Address - Phone:505-757-4644
Mailing Address - Fax:505-757-3049
Practice Address - Street 1:PECOS SCHOOLS HWY 63
Practice Address - Street 2:
Practice Address - City:PECOS
Practice Address - State:NM
Practice Address - Zip Code:87552-0368
Practice Address - Country:US
Practice Address - Phone:505-757-4644
Practice Address - Fax:505-757-3049
Is Sole Proprietor?:No
Enumeration Date:2007-03-01
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM1322225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM000R7048Medicaid