Healthcare Provider Details

I. General information

NPI: 1649371030
Provider Name (Legal Business Name): CHARLES DONALD BLODGETT D.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/26/2006
Last Update Date: 02/15/2020
Certification Date: 02/15/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10025 W GREENFIELD AVE
WEST ALLIS WI
53214-3956
US

IV. Provider business mailing address

10025 W GREENFIELD AVE
WEST ALLIS WI
53214-3956
US

V. Phone/Fax

Practice location:
  • Phone: 414-292-3499
  • Fax: 414-292-3494
Mailing address:
  • Phone: 414-258-9511
  • Fax: 414-607-3948

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number3292-012
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: