Provider Demographics
NPI:1932465598
Name:BOYD, CHARLES JUSTIN
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:JUSTIN
Last Name:BOYD
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:752 HIGHWAY 27 N
Mailing Address - Street 2:
Mailing Address - City:TYLERTOWN
Mailing Address - State:MS
Mailing Address - Zip Code:39667-7904
Mailing Address - Country:US
Mailing Address - Phone:601-303-8364
Mailing Address - Fax:
Practice Address - Street 1:752 HIGHWAY 27 N
Practice Address - Street 2:
Practice Address - City:TYLERTOWN
Practice Address - State:MS
Practice Address - Zip Code:39667-7904
Practice Address - Country:US
Practice Address - Phone:601-303-8364
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-09
Last Update Date:2012-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSPTA2752225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant