Healthcare Provider Details

I. General information

NPI: 1497085963
Provider Name (Legal Business Name): CHARLES KEITH CARPENTER NP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/06/2010
Last Update Date: 02/14/2023
Certification Date: 02/14/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4000 WELLNESS DR
MIDLAND MI
48670-2483
US

IV. Provider business mailing address

PO BOX 3272
SAGINAW MI
48605-3272
US

V. Phone/Fax

Practice location:
  • Phone: 844-832-1956
  • Fax:
Mailing address:
  • Phone: 989-797-1400
  • Fax: 989-797-4077

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number4704271364
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code163WA0400X
TaxonomyAddiction (Substance Use Disorder) Registered Nurse
License Number4704271364
License Number StateMI
# 3
Primary TaxonomyN
Taxonomy Code163WC3500X
TaxonomyCardiac Rehabilitation Registered Nurse
License Number4704271364
License Number StateMI
# 4
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number4704271364
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: