Healthcare Provider Details

I. General information

NPI: 1093598179
Provider Name (Legal Business Name): CHARLES WESLEY ADAMS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/14/2023
Last Update Date: 09/04/2026
Certification Date: 09/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1727 LAKE SHORE PL
EDGEWATER CO
80214-1659
US

IV. Provider business mailing address

1727 LAKE SHORE PL
EDGEWATER CO
80214-1659
US

V. Phone/Fax

Practice location:
  • Phone: 904-444-3545
  • Fax:
Mailing address:
  • Phone: 904-444-3545
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberACD.0002946
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: