Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 224P00000X | Prosthetist | 1201133686 | VA |
NPI | 1205308210 |
---|---|
Provider Name | Clover Charles |
First Address | Lynchburg, VA 24501-3647 |
Second Address | Lynchburg, VA 24501-3647 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 02/01/2019 |
Last Update Date | 30/12/2020 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
NONE | NONE (01) |