Provider Demographics
NPI:1669504114
Name:GAINES, CHARLES WILLIAM (PT)
Entity Type:Individual
Prefix:MR
First Name:CHARLES
Middle Name:WILLIAM
Last Name:GAINES
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1988 E AVERY DR
Mailing Address - Street 2:
Mailing Address - City:PALM SPRINGS
Mailing Address - State:CA
Mailing Address - Zip Code:92264-8607
Mailing Address - Country:US
Mailing Address - Phone:760-320-5843
Mailing Address - Fax:
Practice Address - Street 1:1988 E AVERY DR
Practice Address - Street 2:
Practice Address - City:PALM SPRINGS
Practice Address - State:CA
Practice Address - Zip Code:92264-8607
Practice Address - Country:US
Practice Address - Phone:760-320-5843
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT10935225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist