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General NPI Number Information
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NPI Number | 1154503605
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Entity Type | Organization
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Legal Business Name | CHARLES A WARDLE
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Dates
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Enumeration Date | 11/27/2007
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Last Update Date | 09/23/2010
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Provider Practice Location Address
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Address Line | 1426 COMMERCE AVE
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City | LONGVIEW
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State | WA
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Zip | 98632-3720
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Country | US
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Telephone | 360-423-7650
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Fax | 360-423-2346
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Provider Business Mailing Address
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Address Line | PO BOX 928
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City | LONGVIEW
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State | WA
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Zip | 98632-7582
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Country | US
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Telephone | 360-423-7650
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Fax | 360-423-2346
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Authorized Official
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Title or Position | OFFICE MANAGER
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Name | MRS. DARCY DAVIS
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Credential | L.D.O.
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Telephone | 360-423-7650
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 152W00000X
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Taxonomy Name | Optometrist
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License Number | 907
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License Number State | WA
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