Basic Information
| Provider Information | |||||||||
| NPI: | 1699868299 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DALE | ||||||||
| FirstName: | CHARLES | ||||||||
| MiddleName: | LYNN | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | C.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11140 105TH AVENUE N. | ||||||||
| Address2: | |||||||||
| City: | LARGO | ||||||||
| State: | FL | ||||||||
| PostalCode: | 337784101 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7273975583 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 10000 BAY PINES BLVD | ||||||||
| Address2: | PROSTHETIC BLDG 23 | ||||||||
| City: | BAY PINES | ||||||||
| State: | FL | ||||||||
| PostalCode: | 337445005 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7273986661 | ||||||||
| FaxNumber: | 7273989538 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/02/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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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 | 225000000X | N/A | FL | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Orthotic Fitter |
No ID Information.