Provider Demographics
NPI:1336410117
Name:LINCOLN, CHARLES
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:
Last Name:LINCOLN
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 1:15301 IH 35 STE A
Mailing Address - Street 2:
Mailing Address - City:PFLUGERVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:78660-3188
Mailing Address - Country:US
Mailing Address - Phone:512-436-0820
Mailing Address - Fax:512-828-8784
Practice Address - Street 1:15301 IH 35 STE A
Practice Address - Street 2:
Practice Address - City:PFLUGERVILLE
Practice Address - State:TX
Practice Address - Zip Code:78660-3188
Practice Address - Country:US
Practice Address - Phone:512-436-0820
Practice Address - Fax:512-828-8784
Is Sole Proprietor?:No
Enumeration Date:2012-01-25
Last Update Date:2012-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX111218171WV0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171WV0202XOther Service ProvidersContractorVehicle Modifications
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXD001018862OtherAPI