Healthcare Provider Details

I. General information

NPI: 1104750785
Provider Name (Legal Business Name): CHARLES ANGELOPOULOS ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/10/2026
Last Update Date: 06/10/2026
Certification Date: 06/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4 BONNIE DR
LAKE PLACID NY
12946-3062
US

IV. Provider business mailing address

4 BONNIE DR
LAKE PLACID NY
12946-3062
US

V. Phone/Fax

Practice location:
  • Phone: 518-524-1187
  • Fax: 518-523-7889
Mailing address:
  • Phone: 518-524-1187
  • Fax: 518-523-7889

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: