Healthcare Provider Details

I. General information

NPI: 1962008615
Provider Name (Legal Business Name): CHARLES COLLINS LMT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/08/2020
Last Update Date: 12/08/2020
Certification Date: 12/08/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4606 W JEFFERSON BLVD
FORT WAYNE IN
46804-6826
US

IV. Provider business mailing address

4606 W JEFFERSON BLVD
FORT WAYNE IN
46804-6826
US

V. Phone/Fax

Practice location:
  • Phone: 260-459-1111
  • Fax:
Mailing address:
  • Phone: 260-459-1111
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMT22007188
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: