Healthcare Provider Details

I. General information

NPI: 1558720458
Provider Name (Legal Business Name): CHARLES MCDONALD JR. RRT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/19/2016
Last Update Date: 02/19/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1460 G ST
SPRINGFIELD OR
97477-4112
US

IV. Provider business mailing address

515 SPRUCE CT
CRESWELL OR
97426-9589
US

V. Phone/Fax

Practice location:
  • Phone: 541-726-4467
  • Fax:
Mailing address:
  • Phone: 541-285-7435
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code227900000X
TaxonomyRegistered Respiratory Therapist
License NumberRTP10121581
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: