Healthcare Provider Details

I. General information

NPI: 1669488664
Provider Name (Legal Business Name): CHARLES R. MORTHLAND ILLINOIS LICENSE # 0
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/31/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19 W FRANKFORT PLZ
WEST FRANKFORT IL
62896-4964
US

IV. Provider business mailing address

19 W FRANKFORT PLZ
WEST FRANKFORT IL
62896-4964
US

V. Phone/Fax

Practice location:
  • Phone: 618-937-2492
  • Fax: 618-937-3418
Mailing address:
  • Phone: 618-937-2492
  • Fax: 618-937-3418

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code237700000X
TaxonomyHearing Instrument Specialist
License Number0206
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: