MEDICARE: CHARLES SHARP SR.

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	172M00000X	Mechanotherapist	17903	OR

General Provider Information

NPI Number	:	1720404866
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CHARLES SHARP SR.

Provider Business Mailing Address
First Line	:	3922 SE 49TH AVE
Second Line	:
City	:	PORTLAND
State	:	OR
Zip	:	97206
Country	:	US
Telephone Number	:	920-268-8867
Fax Number	:

Provider Business Practice Location Address
First Line	:	3922 SE 49TH AVE
Second Line	:
City	:	PORTLAND
State	:	OR
Zip	:	97206-3018
Country	:	US
Telephone Number	:	920-268-8867
Fax Number	:

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

Provider Enumeration Date	:	03/13/2014
Last Update Date	:	03/13/2014

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Directions to “ CHARLES SHARP SR. ” Practice Location

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