Provider Demographics
NPI:1811759178
Name:ALLEN, CHARLES MICHAEL
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:MICHAEL
Last Name:ALLEN
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 1:5530 E BLARNEY PL APT 2
Mailing Address - Street 2:
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57110-3716
Mailing Address - Country:US
Mailing Address - Phone:605-231-3515
Mailing Address - Fax:
Practice Address - Street 1:5530 E BLARNEY PL APT 2
Practice Address - Street 2:
Practice Address - City:SIOUX FALLS
Practice Address - State:SD
Practice Address - Zip Code:57110-3716
Practice Address - Country:US
Practice Address - Phone:605-231-3515
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-23
Last Update Date:2024-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD02605766172A00000X
344600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes344600000XTransportation ServicesTaxi
No172A00000XOther Service ProvidersDriver