Healthcare Provider Details

I. General information

NPI: 1477812584
Provider Name (Legal Business Name): CHARLTON EDWIN BELL
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/09/2012
Last Update Date: 05/09/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7306 MAPLE TREE DR
JACKSONVILLE FL
32277-2806
US

IV. Provider business mailing address

7306 MAPLE TREE DR
JACKSONVILLE FL
32277-2806
US

V. Phone/Fax

Practice location:
  • Phone: 904-619-8730
  • Fax: 904-619-8730
Mailing address:
  • Phone: 904-619-8730
  • Fax: 904-619-8730

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code311ZA0620X
TaxonomyAdult Care Home Facility
License Number6906529
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: