Provider Demographics
NPI:1316347891
Name:MITCHELL, CHARLES LESTER TALAN (PT, DPT)
Entity type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:LESTER TALAN
Last Name:MITCHELL
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:218 DONDANVILLE RD
Mailing Address - Street 2:
Mailing Address - City:SAINT AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32080-6405
Mailing Address - Country:US
Mailing Address - Phone:901-581-8057
Mailing Address - Fax:
Practice Address - Street 1:520 PALM COAST PKWY SW
Practice Address - Street 2:ST # 101
Practice Address - City:PALM COAST
Practice Address - State:FL
Practice Address - Zip Code:32137-4742
Practice Address - Country:US
Practice Address - Phone:386-446-4107
Practice Address - Fax:386-447-2161
Is Sole Proprietor?:No
Enumeration Date:2014-09-03
Last Update Date:2014-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT29295225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist