Healthcare Provider Details

I. General information

NPI: 1275502197
Provider Name (Legal Business Name): CHARLES FREDERICK PAYNE PT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/14/2006
Last Update Date: 12/27/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

216 NORTH SECOND ST
AMITE LA
70422-0398
US

IV. Provider business mailing address

PO BOX 398
AMITE LA
70422-0398
US

V. Phone/Fax

Practice location:
  • Phone: 985-748-7878
  • Fax: 985-748-2837
Mailing address:
  • Phone: 985-748-7878
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number1013
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: