Provider Demographics
NPI:1609926229
Name:EDINGTON, CHARLES JEFFREY (OTR)
Entity Type:Individual
Prefix:MR
First Name:CHARLES
Middle Name:JEFFREY
Last Name:EDINGTON
Suffix:
Gender:M
Credentials:OTR
Other - Prefix:MR
Other - First Name:JEFF
Other - Middle Name:
Other - Last Name:EDINGTON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:OTR
Mailing Address - Street 1:48 BRECKENRIDGE CT
Mailing Address - Street 2:
Mailing Address - City:MOUNTAIN HOME
Mailing Address - State:AR
Mailing Address - Zip Code:72653-9238
Mailing Address - Country:US
Mailing Address - Phone:870-656-8567
Mailing Address - Fax:
Practice Address - Street 1:18 COUNTY ROAD 458
Practice Address - Street 2:
Practice Address - City:MOUNTAIN HOME
Practice Address - State:AR
Practice Address - Zip Code:72653-8212
Practice Address - Country:US
Practice Address - Phone:870-425-5252
Practice Address - Fax:870-425-5254
Is Sole Proprietor?:No
Enumeration Date:2007-01-12
Last Update Date:2021-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AROTR1611225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR142156721Medicaid