Provider Demographics
NPI:1023074457
Name:FOX, CHARLES RICHARD (LAT, ATC)
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:RICHARD
Last Name:FOX
Suffix:
Gender:M
Credentials:LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9920 COUNTY ROAD 210
Mailing Address - Street 2:
Mailing Address - City:BERTRAM
Mailing Address - State:TX
Mailing Address - Zip Code:78605
Mailing Address - Country:US
Mailing Address - Phone:512-355-3086
Mailing Address - Fax:
Practice Address - Street 1:1000 THE GREEN MILE
Practice Address - Street 2:
Practice Address - City:BURNET
Practice Address - State:TX
Practice Address - Zip Code:78611
Practice Address - Country:US
Practice Address - Phone:512-756-4501
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXATO772174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist