Provider Demographics
NPI:1942578299
Name:LAUDER, CHARLES MORRIS III (ATC, ATL)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:MORRIS
Last Name:LAUDER
Suffix:III
Gender:M
Credentials:ATC, ATL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26041 W 10TH STREET RD
Mailing Address - Street 2:
Mailing Address - City:CENTRALIA
Mailing Address - State:IL
Mailing Address - Zip Code:62801-5947
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1441 W BROADWAY
Practice Address - Street 2:
Practice Address - City:CENTRALIA
Practice Address - State:IL
Practice Address - Zip Code:62801-5613
Practice Address - Country:US
Practice Address - Phone:618-532-0810
Practice Address - Fax:618-532-0812
Is Sole Proprietor?:No
Enumeration Date:2011-12-01
Last Update Date:2011-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL096.0029872255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer