Provider Demographics
NPI:1619422045
Name:BOODY, CHARLES STEVEN JR (LPN)
Entity Type:Individual
Prefix:MR
First Name:CHARLES
Middle Name:STEVEN
Last Name:BOODY
Suffix:JR
Gender:M
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3639 BOWEN RD
Mailing Address - Street 2:
Mailing Address - City:LANCASTER
Mailing Address - State:NY
Mailing Address - Zip Code:14086-9432
Mailing Address - Country:US
Mailing Address - Phone:716-982-1604
Mailing Address - Fax:
Practice Address - Street 1:3639 BOWEN RD
Practice Address - Street 2:
Practice Address - City:LANCASTER
Practice Address - State:NY
Practice Address - Zip Code:14086-9432
Practice Address - Country:US
Practice Address - Phone:716-982-1604
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-15
Last Update Date:2016-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY324305164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse