Healthcare Provider Details

I. General information

NPI: 1285665497
Provider Name (Legal Business Name): CHARLES MARTIN BOWER ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/05/2006
Last Update Date: 07/15/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3545 S NATIONAL AVE
SPRINGFIELD MO
65807-7310
US

IV. Provider business mailing address

5425 S HONEYSUCKLE LN
BATTLEFIELD MO
65619-9350
US

V. Phone/Fax

Practice location:
  • Phone: 417-988-5071
  • Fax: 417-269-5508
Mailing address:
  • Phone: 417-209-4829
  • Fax: 417-269-5508

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number2005008042
License Number StateMO

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: