Provider Demographics
NPI:1861034613
Name:EGBERT, CHARLES DANIEL JR (HS DIPLOMA, CAREGIVE)
Entity Type:Individual
Prefix:MR
First Name:CHARLES
Middle Name:DANIEL
Last Name:EGBERT
Suffix:JR
Gender:M
Credentials:HS DIPLOMA, CAREGIVE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:450 E. STATE ST. P.O. BOX 1068
Mailing Address - Street 2:
Mailing Address - City:ADAMS
Mailing Address - State:WI
Mailing Address - Zip Code:53910
Mailing Address - Country:US
Mailing Address - Phone:608-339-7600
Mailing Address - Fax:
Practice Address - Street 1:1105 COUNTY ROAD C
Practice Address - Street 2:
Practice Address - City:ARKDALE
Practice Address - State:WI
Practice Address - Zip Code:54613
Practice Address - Country:US
Practice Address - Phone:608-403-2440
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-14
Last Update Date:2019-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747A0650XNursing Service Related ProvidersTechnicianAttendant Care Provider