Provider Demographics
NPI:1538302211
Name:BRANCH, CHARLES (LMT)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:
Last Name:BRANCH
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10870 PEAR BLOSSOM CT
Mailing Address - Street 2:APT. C
Mailing Address - City:SAINT ANN
Mailing Address - State:MO
Mailing Address - Zip Code:63074-1245
Mailing Address - Country:US
Mailing Address - Phone:314-327-7604
Mailing Address - Fax:
Practice Address - Street 1:10870 PEAR BLOSSOM CT
Practice Address - Street 2:APT. C
Practice Address - City:SAINT ANN
Practice Address - State:MO
Practice Address - Zip Code:63074-1245
Practice Address - Country:US
Practice Address - Phone:314-327-7604
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-04-10
Last Update Date:2009-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2008026601172M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172M00000XOther Service ProvidersMechanotherapist