Provider Demographics
NPI:1932578192
Name:BISHOP, CHARLES (LAC)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:
Last Name:BISHOP
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:70 BRANDON LN
Mailing Address - Street 2:
Mailing Address - City:GRAND MARAIS
Mailing Address - State:MN
Mailing Address - Zip Code:55604-2249
Mailing Address - Country:US
Mailing Address - Phone:218-210-0123
Mailing Address - Fax:
Practice Address - Street 1:1910 W HIGHWAY 61
Practice Address - Street 2:
Practice Address - City:GRAND MARAIS
Practice Address - State:MN
Practice Address - Zip Code:55604-7508
Practice Address - Country:US
Practice Address - Phone:218-210-0123
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-17
Last Update Date:2020-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1750171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist