Provider Demographics
NPI:1295440204
Name:FAWCETT, CHARLIE JOSEPH (SON)
Entity type:Individual
Prefix:
First Name:CHARLIE
Middle Name:JOSEPH
Last Name:FAWCETT
Suffix:
Gender:M
Credentials:SON
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11971 JUNIPER WAY APT 335
Mailing Address - Street 2:
Mailing Address - City:GRAND BLANC
Mailing Address - State:MI
Mailing Address - Zip Code:48439-2142
Mailing Address - Country:US
Mailing Address - Phone:810-676-3222
Mailing Address - Fax:
Practice Address - Street 1:4150 BOYSENBERRY LN
Practice Address - Street 2:
Practice Address - City:BURTON
Practice Address - State:MI
Practice Address - Zip Code:48529-2242
Practice Address - Country:US
Practice Address - Phone:810-676-3220
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-16
Last Update Date:2023-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI000000000OtherVA