Healthcare Provider Details

I. General information

NPI: 1841422565
Provider Name (Legal Business Name): VICKIE CHARITY BLACK LPTA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/13/2009
Last Update Date: 08/13/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10531 SHADY LANE
CHARLES CITY VA
23030-2847
US

IV. Provider business mailing address

10531 SHADY LANE
CHARLES CITY VA
23030-2847
US

V. Phone/Fax

Practice location:
  • Phone: 804-829-5310
  • Fax:
Mailing address:
  • Phone: 804-829-5310
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number2306601258
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: