Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 111NN1001X | Nutrition | 2301007576 | MI |
NPI | 1518094614 |
---|---|
Provider Name | Dr. Charles Howard Lange |
First Address | Acme, MI 49610-0329 |
Second Address | Acme, MI 49610 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 27/02/2007 |
Last Update Date | 08/07/2007 |