Provider Demographics
NPI:1568097343
Name:MOREY, CHARLES KEITH III
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:KEITH
Last Name:MOREY
Suffix:III
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 1:1825 N ROCKSIDE RD
Mailing Address - Street 2:
Mailing Address - City:WASILLA
Mailing Address - State:AK
Mailing Address - Zip Code:99654-3131
Mailing Address - Country:US
Mailing Address - Phone:907-414-0168
Mailing Address - Fax:
Practice Address - Street 1:1825 N ROCKSIDE RD
Practice Address - Street 2:
Practice Address - City:WASILLA
Practice Address - State:AK
Practice Address - Zip Code:99654-3131
Practice Address - Country:US
Practice Address - Phone:907-414-0168
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-11
Last Update Date:2020-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK2100910344600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes344600000XTransportation ServicesTaxi
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK180144Medicaid