Healthcare Provider Details

I. General information

NPI: 1649810540
Provider Name (Legal Business Name): CHARLES L CARR JR DO PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/09/2020
Last Update Date: 01/09/2020
Certification Date: 01/09/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4335 CHEVAL BLVD
LUTZ FL
33558-5328
US

IV. Provider business mailing address

3959 VAN DYKE RD # 259
LUTZ FL
33558-8025
US

V. Phone/Fax

Practice location:
  • Phone: 207-332-0774
  • Fax:
Mailing address:
  • Phone: 207-332-0774
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code204C00000X
TaxonomySports Medicine (Neuromusculoskeletal Medicine) Physician
License Number
License Number State

VIII. Authorized Official

Name: CHARLES L CARR JR.
Title or Position: PRESIDENT
Credential: DO
Phone: 207-332-0774