Provider Demographics
NPI:1942427091
Name:LUTES, CHARLES PRESTON (ATC, LAT, EMT)
Entity Type:Individual
Prefix:MR
First Name:CHARLES
Middle Name:PRESTON
Last Name:LUTES
Suffix:
Gender:M
Credentials:ATC, LAT, EMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1702 HASKELL DR
Mailing Address - Street 2:
Mailing Address - City:RUSTON
Mailing Address - State:LA
Mailing Address - Zip Code:71270-5319
Mailing Address - Country:US
Mailing Address - Phone:318-255-0474
Mailing Address - Fax:
Practice Address - Street 1:1200 S FARMERVILLE ST
Practice Address - Street 2:
Practice Address - City:RUSTON
Practice Address - State:LA
Practice Address - Zip Code:71270-5941
Practice Address - Country:US
Practice Address - Phone:318-251-6373
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAATH.2000432255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer