Provider Demographics
NPI:1013671577
Name:FAGLIE, CHARLESTON
Entity Type:Individual
Prefix:
First Name:CHARLESTON
Middle Name:
Last Name:FAGLIE
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:MARTIN ARMY COMMUNITY HOSPITAL
Mailing Address - Street 2:6600 VAN AALST BLVD, BLDG 9250
Mailing Address - City:FT MOORE
Mailing Address - State:GA
Mailing Address - Zip Code:31905
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:MARTIN ARMY COMMUNITY HOSPITAL
Practice Address - Street 2:6600 VAN AALST BLVD, BLDG 9250
Practice Address - City:FT MOORE
Practice Address - State:GA
Practice Address - Zip Code:31905
Practice Address - Country:US
Practice Address - Phone:409-771-2286
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-29
Last Update Date:2024-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1370634225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist