Provider Demographics
NPI:1134239254
Name:ACEVEDO, CHARLES R (PT)
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:R
Last Name:ACEVEDO
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 6518
Mailing Address - Street 2:
Mailing Address - City:NORTH LOGAN
Mailing Address - State:UT
Mailing Address - Zip Code:84341-6518
Mailing Address - Country:US
Mailing Address - Phone:435-752-5200
Mailing Address - Fax:435-752-5228
Practice Address - Street 1:2310 N 400 E
Practice Address - Street 2:STE C
Practice Address - City:NORTH LOGAN
Practice Address - State:UT
Practice Address - Zip Code:84341
Practice Address - Country:US
Practice Address - Phone:435-752-5200
Practice Address - Fax:435-752-5228
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT1205752401225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
R60842Medicare UPIN