Provider Demographics
NPI:1831673961
Name:CHARLES, KACEY BROOKE
Entity Type:Individual
Prefix:
First Name:KACEY
Middle Name:BROOKE
Last Name:CHARLES
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:536 MAIN ST W
Mailing Address - Street 2:
Mailing Address - City:MT CARMEL
Mailing Address - State:TN
Mailing Address - Zip Code:37645-3564
Mailing Address - Country:US
Mailing Address - Phone:423-256-3232
Mailing Address - Fax:
Practice Address - Street 1:536 MAIN ST W
Practice Address - Street 2:
Practice Address - City:MT CARMEL
Practice Address - State:TN
Practice Address - Zip Code:37645-3564
Practice Address - Country:US
Practice Address - Phone:423-256-3232
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-25
Last Update Date:2018-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN3080111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor