Provider Demographics
NPI:1578763975
Name:SAMMONS, CHARLES HOWARD SR
Entity Type:Individual
Prefix:MR
First Name:CHARLES
Middle Name:HOWARD
Last Name:SAMMONS
Suffix:SR
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 1:3129 TARHEEL CLUBHOUSE RD
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27604-9675
Mailing Address - Country:US
Mailing Address - Phone:919-217-0112
Mailing Address - Fax:
Practice Address - Street 1:3129 TARHEEL CLUBHOUSE RD
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27604-9675
Practice Address - Country:US
Practice Address - Phone:919-217-0112
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-23
Last Update Date:2007-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCMHL-092-470311ZA0620X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home