Healthcare Provider Details

I. General information

NPI: 1245227743
Provider Name (Legal Business Name): CHARLES J LATENDRESSE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/30/2005
Last Update Date: 10/14/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1506 G AVE
GRUNDY CENTER IA
50638-1038
US

IV. Provider business mailing address

1506 G AVE PO BOX 128
GRUNDY CENTER IA
50638-1038
US

V. Phone/Fax

Practice location:
  • Phone: 319-824-3181
  • Fax: 319-824-6680
Mailing address:
  • Phone: 319-824-3181
  • Fax: 319-824-6680

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number21831
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: