Provider Demographics
NPI:1740541382
Name:FITZSIMONS, CHARLES L
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:L
Last Name:FITZSIMONS
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 1:100 MULLINS DR
Mailing Address - Street 2:SUITE A-1
Mailing Address - City:LEBANON
Mailing Address - State:OR
Mailing Address - Zip Code:97355-3982
Mailing Address - Country:US
Mailing Address - Phone:541-451-6920
Mailing Address - Fax:541-451-6924
Practice Address - Street 1:100 MULLINS DR
Practice Address - Street 2:SUITE A-1
Practice Address - City:LEBANON
Practice Address - State:OR
Practice Address - Zip Code:97355-3982
Practice Address - Country:US
Practice Address - Phone:541-451-6920
Practice Address - Fax:541-451-6924
Is Sole Proprietor?:No
Enumeration Date:2012-05-30
Last Update Date:2012-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program