Provider Demographics
NPI:1760408611
Name:CHARLES S THEOFILOS MD
Entity Type:Organization
Organization Name:CHARLES S THEOFILOS MD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGED CARE SPEC ALLSCRIPTS
Authorized Official - Prefix:
Authorized Official - First Name:DIRENDIA
Authorized Official - Middle Name:
Authorized Official - Last Name:SHACKELFORD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:800-654-0889
Mailing Address - Street 1:THE SPINE CENTER
Mailing Address - Street 2:11621 KEW GARDENS AVE STE 101
Mailing Address - City:PALM BEACH GARDENS
Mailing Address - State:FL
Mailing Address - Zip Code:33410
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:THE SPINE CENTER
Practice Address - Street 2:11621 KEW GARDENS AVE STE 101
Practice Address - City:PALM BEACH GARDENS
Practice Address - State:FL
Practice Address - Zip Code:33410
Practice Address - Country:US
Practice Address - Phone:561-630-3870
Practice Address - Fax:561-630-3680
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-14
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME64328332900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332900000XSuppliersNon-Pharmacy Dispensing Site
Provider Identifiers
StateIdentifier IDID TypeIssuer
1014276OtherOTHER ID NUMBER-COMMERCIAL NUMBER