Provider Demographics
NPI:1588088629
Name:PETERS, CHARLES
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:
Last Name:PETERS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4105 FORT HENRY DR STE 300
Mailing Address - Street 2:
Mailing Address - City:KINGSPORT
Mailing Address - State:TN
Mailing Address - Zip Code:37663-2256
Mailing Address - Country:US
Mailing Address - Phone:423-239-1550
Mailing Address - Fax:
Practice Address - Street 1:105 MEADOW VIEW RD STE 4
Practice Address - Street 2:
Practice Address - City:BRISTOL
Practice Address - State:TN
Practice Address - Zip Code:37620-1726
Practice Address - Country:US
Practice Address - Phone:423-844-6935
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-02-10
Last Update Date:2024-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist