Healthcare Provider Details

I. General information

NPI: 1588747547
Provider Name (Legal Business Name): CHARLES PAUL HENDRIX OD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/23/2006
Last Update Date: 04/21/2021
Certification Date: 04/21/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

240 CORPORATE DRIVE
BEAVER DAM WI
53916-3115
US

IV. Provider business mailing address

240 CORPORATE DRIVE
BEAVER DAM WI
53916-3115
US

V. Phone/Fax

Practice location:
  • Phone: 920-887-1151
  • Fax:
Mailing address:
  • Phone: 920-887-1151
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152WC0802X
TaxonomyCorneal and Contact Management Optometrist
License Number2549
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code152WP0200X
TaxonomyPediatric Optometrist
License Number2549
License Number StateWI
# 3
Primary TaxonomyN
Taxonomy Code152WV0400X
TaxonomyVision Therapy Optometrist
License Number2549
License Number StateWI
# 4
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number2549
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: