Provider Demographics
NPI:1023280724
Name:MCGLOTHLIN, CHAS L
Entity type:Individual
Prefix:
First Name:CHAS
Middle Name:L
Last Name:MCGLOTHLIN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1107B E BROADWAY
Mailing Address - Street 2:
Mailing Address - City:SWEETWATER
Mailing Address - State:TX
Mailing Address - Zip Code:79556
Mailing Address - Country:US
Mailing Address - Phone:325-235-9001
Mailing Address - Fax:325-235-9005
Practice Address - Street 1:1107B E BROADWAY
Practice Address - Street 2:
Practice Address - City:SWEETWATER
Practice Address - State:TX
Practice Address - Zip Code:79556
Practice Address - Country:US
Practice Address - Phone:325-235-9001
Practice Address - Fax:325-235-9005
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-02
Last Update Date:2008-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX0052491332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX4089970001Medicare NSC