Provider Demographics
NPI:1528506789
Name:RAMOS, CHARLIE DALE TORTONA (PTA)
Entity type:Individual
Prefix:MR
First Name:CHARLIE DALE
Middle Name:TORTONA
Last Name:RAMOS
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1551 N STATE HIGHWAY 161
Mailing Address - Street 2:APT 1811
Mailing Address - City:GRAND PRAIRIE
Mailing Address - State:TX
Mailing Address - Zip Code:75050-7077
Mailing Address - Country:US
Mailing Address - Phone:310-259-1878
Mailing Address - Fax:
Practice Address - Street 1:3055 BARDIN RD
Practice Address - Street 2:#200
Practice Address - City:GRAND PRAIRIE
Practice Address - State:TX
Practice Address - Zip Code:75052-3816
Practice Address - Country:US
Practice Address - Phone:672-522-2200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-02-08
Last Update Date:2017-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2121409225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant