Provider Demographics
NPI:1316453384
Name:WEAVER, CHARLES WADE (ATC, AT, LAT)
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:WADE
Last Name:WEAVER
Suffix:
Gender:M
Credentials:ATC, AT, LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11399 DAVIS RD
Mailing Address - Street 2:
Mailing Address - City:MIDDLEVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:49333-8652
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:11399 DAVIS RD
Practice Address - Street 2:
Practice Address - City:MIDDLEVILLE
Practice Address - State:MI
Practice Address - Zip Code:49333-8652
Practice Address - Country:US
Practice Address - Phone:936-443-6289
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-12-28
Last Update Date:2017-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
20000080062255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2601001771OtherATHLETIC TRAINER LICENSE
TXAT2652OtherLICENSED ATHLETIC TRAINER
2000008006OtherATHLETIC TRAINING CERTIFICATION, BOC