Provider Demographics
NPI:1780989533
Name:BORDES, CHARLES
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:
Last Name:BORDES
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 1:59 DEAN STREET
Mailing Address - Street 2:
Mailing Address - City:ISLANDIA
Mailing Address - State:NY
Mailing Address - Zip Code:11749-1715
Mailing Address - Country:US
Mailing Address - Phone:631-786-9418
Mailing Address - Fax:631-630-6527
Practice Address - Street 1:59 DEAN STREET
Practice Address - Street 2:
Practice Address - City:ISLANDIA
Practice Address - State:NY
Practice Address - Zip Code:11749-1715
Practice Address - Country:US
Practice Address - Phone:631-786-9418
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-01-25
Last Update Date:2011-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY295085-1164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse