Provider Demographics
NPI:1205104825
Name:KIRK, CHARLES EDWARD (CHP)
Entity type:Individual
Prefix:MR
First Name:CHARLES
Middle Name:EDWARD
Last Name:KIRK
Suffix:
Gender:M
Credentials:CHP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9 HILLSIDE ROAD
Mailing Address - Street 2:BOX 86
Mailing Address - City:BUCKLAND
Mailing Address - State:AK
Mailing Address - Zip Code:99727
Mailing Address - Country:US
Mailing Address - Phone:907-494-2122
Mailing Address - Fax:907-494-2104
Practice Address - Street 1:9 HILLSIDE ROAD
Practice Address - Street 2:86
Practice Address - City:BUCKLAND
Practice Address - State:AK
Practice Address - Zip Code:99727
Practice Address - Country:US
Practice Address - Phone:907-494-2122
Practice Address - Fax:907-494-2104
Is Sole Proprietor?:No
Enumeration Date:2011-12-09
Last Update Date:2011-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK04-677-P172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker