Provider Demographics
NPI:1922278209
Name:CHARLES WILLIAM WENTWORTH, DPM
Entity Type:Organization
Organization Name:CHARLES WILLIAM WENTWORTH, DPM
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:LISA
Authorized Official - Middle Name:
Authorized Official - Last Name:WHITE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:269-968-6353
Mailing Address - Street 1:359 TERRITORIAL RD W
Mailing Address - Street 2:
Mailing Address - City:BATTLE CREEK
Mailing Address - State:MI
Mailing Address - Zip Code:49015-3245
Mailing Address - Country:US
Mailing Address - Phone:269-968-6353
Mailing Address - Fax:
Practice Address - Street 1:359 W TERRITORIAL RD
Practice Address - Street 2:
Practice Address - City:BATTLE CREEK
Practice Address - State:MI
Practice Address - Zip Code:49015
Practice Address - Country:US
Practice Address - Phone:269-968-6353
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-03
Last Update Date:2008-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4434720001Medicare NSC