Provider Demographics
NPI:1306812409
Name:MARTH, CHARLES PATRICK (ATC/L)
Entity type:Individual
Prefix:MR
First Name:CHARLES
Middle Name:PATRICK
Last Name:MARTH
Suffix:
Gender:M
Credentials:ATC/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2412 VENTURA DR
Mailing Address - Street 2:
Mailing Address - City:PLAINFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:60586-8442
Mailing Address - Country:US
Mailing Address - Phone:815-609-2504
Mailing Address - Fax:
Practice Address - Street 1:1755 S WOLF RD
Practice Address - Street 2:
Practice Address - City:DES PLAINES
Practice Address - State:IL
Practice Address - Zip Code:60018-1923
Practice Address - Country:US
Practice Address - Phone:847-803-5901
Practice Address - Fax:847-803-5991
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer