Provider Demographics
NPI:1922491513
Name:CHARLES GOLIGHTLY
Entity Type:Organization
Organization Name:CHARLES GOLIGHTLY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MASSAGE THERAPIST
Authorized Official - Prefix:MR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:ANTHONY
Authorized Official - Last Name:GOLIGHTLY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-936-9455
Mailing Address - Street 1:1797 N AZURITE DR
Mailing Address - Street 2:
Mailing Address - City:KUNA
Mailing Address - State:ID
Mailing Address - Zip Code:83634-5370
Mailing Address - Country:US
Mailing Address - Phone:208-936-9455
Mailing Address - Fax:
Practice Address - Street 1:1797 N AZURITE DR
Practice Address - Street 2:
Practice Address - City:KUNA
Practice Address - State:ID
Practice Address - Zip Code:83634-5370
Practice Address - Country:US
Practice Address - Phone:208-936-9455
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-03-06
Last Update Date:2015-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDMASG-1948225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty