Provider Demographics
NPI:1649391855
Name:CROAL, CHARLES J (PT)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:J
Last Name:CROAL
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:CHUCK
Other - Middle Name:
Other - Last Name:CROAL
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:805 SW INDUSTRIAL WAY
Mailing Address - Street 2:SUITE 3
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97702-1093
Mailing Address - Country:US
Mailing Address - Phone:541-585-2529
Mailing Address - Fax:541-585-2535
Practice Address - Street 1:51600 HUNTINGTON RD
Practice Address - Street 2:SUITE B
Practice Address - City:LAPINE
Practice Address - State:OR
Practice Address - Zip Code:97739-9626
Practice Address - Country:US
Practice Address - Phone:541-536-7443
Practice Address - Fax:541-536-7805
Is Sole Proprietor?:No
Enumeration Date:2007-04-03
Last Update Date:2010-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR2583225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR158751Medicaid
ORR147036Medicare PIN