Provider Demographics
NPI:1629435706
Name:CHARLES, ALFRED
Entity Type:Individual
Prefix:
First Name:ALFRED
Middle Name:
Last Name:CHARLES
Suffix:
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 1:16352 NW 17TH ST
Mailing Address - Street 2:
Mailing Address - City:PEMBROKE PINES
Mailing Address - State:FL
Mailing Address - Zip Code:33028-1722
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:401 ORANGE PL
Practice Address - Street 2:
Practice Address - City:WAUCHULA
Practice Address - State:FL
Practice Address - Zip Code:33873-3417
Practice Address - Country:US
Practice Address - Phone:863-773-3231
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-01-20
Last Update Date:2016-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOT16428225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist