Healthcare Provider Details

I. General information

NPI: 1437257540
Provider Name (Legal Business Name): CHARLES L ANDERSON BC-HIS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/20/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

230 S GRANT ST
FAIRMONT MN
56031-3936
US

IV. Provider business mailing address

230 S GRANT ST
FAIRMONT MN
56031-3936
US

V. Phone/Fax

Practice location:
  • Phone: 507-235-5323
  • Fax:
Mailing address:
  • Phone: 507-235-5323
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code237700000X
TaxonomyHearing Instrument Specialist
License Number2080
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code237700000X
TaxonomyHearing Instrument Specialist
License Number00487
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: