Provider Demographics
NPI:1669786646
Name:PATRICK, CHARLES ALLEN JR
Entity type:Individual
Prefix:MR
First Name:CHARLES
Middle Name:ALLEN
Last Name:PATRICK
Suffix:JR
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 1:31964 US HIGHWAY 19 N
Mailing Address - Street 2:
Mailing Address - City:PALM HARBOR
Mailing Address - State:FL
Mailing Address - Zip Code:34684-3730
Mailing Address - Country:US
Mailing Address - Phone:727-786-2503
Mailing Address - Fax:727-786-7949
Practice Address - Street 1:31964 US HIGHWAY 19 N
Practice Address - Street 2:
Practice Address - City:PALM HARBOR
Practice Address - State:FL
Practice Address - Zip Code:34684-3730
Practice Address - Country:US
Practice Address - Phone:727-786-2503
Practice Address - Fax:727-786-7949
Is Sole Proprietor?:No
Enumeration Date:2010-08-02
Last Update Date:2010-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT25743225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist