Provider Demographics
NPI:1831627876
Name:CLAGG, CHARLES (LMT)
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:
Last Name:CLAGG
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:44284 ARLINGTON RD
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:MI
Mailing Address - Zip Code:48187-2144
Mailing Address - Country:US
Mailing Address - Phone:734-883-4874
Mailing Address - Fax:
Practice Address - Street 1:19159 MERRIMAN RD
Practice Address - Street 2:
Practice Address - City:LIVONIA
Practice Address - State:MI
Practice Address - Zip Code:48152
Practice Address - Country:US
Practice Address - Phone:248-477-4408
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-02
Last Update Date:2019-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI7501010100225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI7501010100OtherMICHIGAN DEPARTMENT OF LICENSING AND REGULATORY AFFAIRS