Provider Demographics
NPI:1205308210
Name:CHARLES, CLOVER
Entity type:Individual
Prefix:
First Name:CLOVER
Middle Name:
Last Name:CHARLES
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:476 OAKLEY AVE
Mailing Address - Street 2:
Mailing Address - City:LYNCHBURG
Mailing Address - State:VA
Mailing Address - Zip Code:24501-3647
Mailing Address - Country:US
Mailing Address - Phone:434-444-2579
Mailing Address - Fax:
Practice Address - Street 1:476 OAKLEY AVE
Practice Address - Street 2:
Practice Address - City:LYNCHBURG
Practice Address - State:VA
Practice Address - Zip Code:24501-3647
Practice Address - Country:US
Practice Address - Phone:434-444-2579
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-02
Last Update Date:2020-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA1201133686224P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224P00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersProsthetist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NONEOtherNONE