Provider Demographics
NPI:1689012049
Name:OLIVER, CHARLES CODY JR (PT, DPT)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:CODY
Last Name:OLIVER
Suffix:JR
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3161 S GLACIER BAY WAY
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-7824
Mailing Address - Country:US
Mailing Address - Phone:208-871-3235
Mailing Address - Fax:
Practice Address - Street 1:7211 W FRANKLIN RD
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83709-0926
Practice Address - Country:US
Practice Address - Phone:208-375-4200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-07
Last Update Date:2013-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPT-33072251P0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics