Provider Demographics
NPI:1245772581
Name:JOHN, CHARLES
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:
Last Name:JOHN
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 1:218 MCKENZIE ST UNIT A
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87501-1831
Mailing Address - Country:US
Mailing Address - Phone:785-338-1623
Mailing Address - Fax:
Practice Address - Street 1:218 MCKENZIE ST UNIT A
Practice Address - Street 2:
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87501-1831
Practice Address - Country:US
Practice Address - Phone:785-338-1623
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-11-16
Last Update Date:2016-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician