MEDICARE: CHARLES A OLIVER DC, MPT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	111NR0400X	Rehabilitation Chiropractor	11109	TX
2	225100000X	Physical Therapist	1125649	TX

General Provider Information

NPI Number	:	1386886422
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CHARLES A OLIVER DC, MPT

Provider Business Mailing Address
First Line	:	930 PROTON RD
Second Line	:	SUITE 104
City	:	SAN ANTONIO
State	:	TX
Zip	:	78258-4231
Country	:	US
Telephone Number	:	210-545-1810
Fax Number	:	210-545-1811

Provider Business Practice Location Address
First Line	:	930 PROTON RD
Second Line	:	SUITE 104
City	:	SAN ANTONIO
State	:	TX
Zip	:	78258-4231
Country	:	US
Telephone Number	:	210-545-1810
Fax Number	:	210-545-1811

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/06/2009
Last Update Date	:	04/06/2009

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