Provider Demographics
NPI:1245875814
Name:BREEDING, CHARLES
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:
Last Name:BREEDING
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 1:4004 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:GRASONVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:21638-1252
Mailing Address - Country:US
Mailing Address - Phone:410-924-0623
Mailing Address - Fax:
Practice Address - Street 1:1140 BLADES FARM RD STE 201
Practice Address - Street 2:
Practice Address - City:DENTON
Practice Address - State:MD
Practice Address - Zip Code:21629-3489
Practice Address - Country:US
Practice Address - Phone:410-479-3300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-11-07
Last Update Date:2020-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD27742225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist