Healthcare Provider Details

I. General information

NPI: 1578238846
Provider Name (Legal Business Name): CHARLES DEWAYNE SANDT PTA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/10/2021
Last Update Date: 08/10/2021
Certification Date: 08/10/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1705 JESS PARRISH CT
TITUSVILLE FL
32796-2158
US

IV. Provider business mailing address

1669 PALM RIDGE RD
MELBOURNE FL
32935-4301
US

V. Phone/Fax

Practice location:
  • Phone: 321-269-5720
  • Fax: 321-383-9514
Mailing address:
  • Phone: 321-223-6278
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberPTA31242
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: