Healthcare Provider Details

I. General information

NPI: 1992339550
Provider Name (Legal Business Name): CHARLES-PHILLIP AUSTIN NORTH
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/23/2020
Last Update Date: 02/23/2020
Certification Date: 02/23/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

310 COLLEGE ST
BARBOURVILLE KY
40906-1410
US

IV. Provider business mailing address

1101 EXETER AVE
MIDDLESBORO KY
40965-2323
US

V. Phone/Fax

Practice location:
  • Phone: 800-489-8646
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: