Provider Demographics
NPI:1427110337
Name:RALEY, CHARLES JONATHAN (DC)
Entity type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:JONATHAN
Last Name:RALEY
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:924 N FERDON BLVD
Mailing Address - Street 2:
Mailing Address - City:CRESTVIEW
Mailing Address - State:FL
Mailing Address - Zip Code:32536-1706
Mailing Address - Country:US
Mailing Address - Phone:850-682-3352
Mailing Address - Fax:850-682-3352
Practice Address - Street 1:924 N FERDON BLVD
Practice Address - Street 2:
Practice Address - City:CRESTVIEW
Practice Address - State:FL
Practice Address - Zip Code:32536-1706
Practice Address - Country:US
Practice Address - Phone:850-682-3352
Practice Address - Fax:850-682-3352
Is Sole Proprietor?:No
Enumeration Date:2006-12-15
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH8874111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL70054OtherBLUE CROSS NON-PART. #
FLCH8874OtherFL STATE LICENSE #
FLV06053Medicare UPIN
FL70054OtherBLUE CROSS NON-PART. #
FLCH8874OtherFL STATE LICENSE #