=====================================================
General NPI Number Information
=====================================================
NPI Number | 1316453384
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CHARLES WADE WEAVER ATC, AT, LAT
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/28/2017
-----------------------------------------------------
Last Update Date | 12/28/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 11399 DAVIS RD
-----------------------------------------------------
City | MIDDLEVILLE
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49333-8652
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 936-443-6289
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 11399 DAVIS RD
-----------------------------------------------------
City | MIDDLEVILLE
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49333-8652
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2255A2300X
-----------------------------------------------------
Taxonomy Name | Athletic Trainer
-----------------------------------------------------
License Number | 2000008006
-----------------------------------------------------
License Number State |
-----------------------------------------------------