Provider Demographics
NPI:1639771991
Name:CHARLES, JULBERTHY S
Entity Type:Individual
Prefix:
First Name:JULBERTHY
Middle Name:S
Last Name:CHARLES
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1120 N OCOEE ST
Mailing Address - Street 2:LU CAMPUS BOX # 0911
Mailing Address - City:CLEVELAND
Mailing Address - State:TN
Mailing Address - Zip Code:37311
Mailing Address - Country:US
Mailing Address - Phone:617-682-5242
Mailing Address - Fax:888-385-6227
Practice Address - Street 1:1120 N OCOEE ST
Practice Address - Street 2:LU CAMPUS BOX # 0911
Practice Address - City:CLEVELAND
Practice Address - State:TN
Practice Address - Zip Code:37311
Practice Address - Country:US
Practice Address - Phone:617-682-5242
Practice Address - Fax:888-385-6227
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-11
Last Update Date:2020-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Multi-Specialty
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic TrainerGroup - Multi-Specialty