Provider Demographics
NPI:1134335862
Name:FERGUSON, CHUCK (LMT)
Entity type:Individual
Prefix:
First Name:CHUCK
Middle Name:
Last Name:FERGUSON
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12 FOX HUNT DR
Mailing Address - Street 2:
Mailing Address - City:BEAR
Mailing Address - State:DE
Mailing Address - Zip Code:19701-2534
Mailing Address - Country:US
Mailing Address - Phone:302-836-6150
Mailing Address - Fax:302-836-6294
Practice Address - Street 1:12 FOX HUNT DR
Practice Address - Street 2:
Practice Address - City:BEAR
Practice Address - State:DE
Practice Address - Zip Code:19701-2534
Practice Address - Country:US
Practice Address - Phone:302-836-6150
Practice Address - Fax:302-836-6294
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DE1999201447174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
DEMT-0001046OtherMASSAGE THERAPIST LICENSE