Basic Information
| Provider Information | |||||||||
| NPI: | 1164417895 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BOARDMAN | ||||||||
| FirstName: | CHARLES | ||||||||
| MiddleName: | HOLLOWAY | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | IV | ||||||||
| Credential: | OTR | ||||||||
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| Mailing Information | |||||||||
| Address1: | 355 SW SWEETBREEZE DR | ||||||||
| Address2: | |||||||||
| City: | LAKE CITY | ||||||||
| State: | FL | ||||||||
| PostalCode: | 320243698 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3867553016 | ||||||||
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| Practice Location | |||||||||
| Address1: | 619 SOUTH MARION AVE | ||||||||
| Address2: | NORTH FLORIDA / SOUTH GEORGIA VETERANS HEALTH SYSTEM | ||||||||
| City: | LAKE CITY | ||||||||
| State: | FL | ||||||||
| PostalCode: | 32025 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3867553016 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/19/2005 | ||||||||
| LastUpdateDate: | 02/25/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225X00000X | OT14416FL | FL | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |
ID Information
| ID | Type | State | Issuer | Description | OT14416FL | 01 | FL | FLORIDA DEPARTMENT OF HEALTH | OTHER | AA499343 | 01 | NBCOT | OTHER |