Provider Demographics
NPI:1285143115
Name:HIGGINS, CHARLES JR (RD CSR)
Entity type:Individual
Prefix:MR
First Name:CHARLES
Middle Name:
Last Name:HIGGINS
Suffix:JR
Gender:M
Credentials:RD CSR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1601 E HIGHLAND AVE APT 1082
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85016-0609
Mailing Address - Country:US
Mailing Address - Phone:716-425-2764
Mailing Address - Fax:602-840-4445
Practice Address - Street 1:1601 E HIGHLAND AVE APT 1082
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85016-0609
Practice Address - Country:US
Practice Address - Phone:716-425-2764
Practice Address - Fax:602-840-4445
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-22
Last Update Date:2021-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ1081333133NN1002X, 133VN1005X
133VN1005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133VN1005XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Renal
No133NN1002XDietary & Nutritional Service ProvidersNutritionistNutrition, Education
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ1081333OtherRD CSR