Provider Demographics
NPI:1023341864
Name:KIRCHEM, CHARLES IV (DPT)
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:
Last Name:KIRCHEM
Suffix:IV
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12371 HWY. 90
Mailing Address - Street 2:SUITE D
Mailing Address - City:LULING
Mailing Address - State:LA
Mailing Address - Zip Code:70070
Mailing Address - Country:US
Mailing Address - Phone:985-331-1001
Mailing Address - Fax:985-331-1005
Practice Address - Street 1:12371 HIGHWAY 90
Practice Address - Street 2:SUITE D
Practice Address - City:LULING
Practice Address - State:LA
Practice Address - Zip Code:70070-5114
Practice Address - Country:US
Practice Address - Phone:985-331-1001
Practice Address - Fax:985-331-1005
Is Sole Proprietor?:Yes
Enumeration Date:2009-09-11
Last Update Date:2010-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA07655174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2113712Medicaid