MEDICARE: MR. CHARLES GUILLERMO FAULDS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	133N00000X	Nutritionist

General Provider Information

NPI Number	:	1619379047
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. CHARLES GUILLERMO FAULDS

Provider Business Mailing Address
First Line	:	62 SKYLAND SPRUCE DR
Second Line	:
City	:	FORT STEWART
State	:	GA
Zip	:	31315-1791
Country	:	US
Telephone Number	:	470-262-0912
Fax Number	:

Provider Business Practice Location Address
First Line	:	62 SKYLAND SPRUCE DR
Second Line	:
City	:	FORT STEWART
State	:	GA
Zip	:	31315-1791
Country	:	US
Telephone Number	:	470-262-0912
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/17/2014
Last Update Date	:	09/17/2014

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