Provider Demographics
NPI:1689712291
Name:ROLL, CHARLES S (NCTMB, LMT)
Entity Type:Individual
Prefix:MR
First Name:CHARLES
Middle Name:S
Last Name:ROLL
Suffix:
Gender:M
Credentials:NCTMB, LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:141 SOUTH AVE
Mailing Address - Street 2:SUITE 5
Mailing Address - City:FANWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:07023-1224
Mailing Address - Country:US
Mailing Address - Phone:908-322-0214
Mailing Address - Fax:
Practice Address - Street 1:141 SOUTH AVE
Practice Address - Street 2:SUITE 5
Practice Address - City:FANWOOD
Practice Address - State:NJ
Practice Address - Zip Code:07023-1224
Practice Address - Country:US
Practice Address - Phone:908-322-0214
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA 16610174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist