Healthcare Provider Details

I. General information

NPI: 1740694728
Provider Name (Legal Business Name): CHARLIE ENTERPRISES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/17/2014
Last Update Date: 06/17/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6814 N 91ST ST
MILWAUKEE WI
53224-4711
US

IV. Provider business mailing address

6814 N 91ST ST
MILWAUKEE WI
53224-4711
US

V. Phone/Fax

Practice location:
  • Phone: 414-395-5025
  • Fax:
Mailing address:
  • Phone: 414-395-5025
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code347C00000X
TaxonomyPrivate Vehicle
License NumberJ5251407021304
License Number StateWI

VIII. Authorized Official

Name: MR. CHARLES JOHNSON III
Title or Position: OWNER
Credential:
Phone: 414-395-5025