Provider Demographics
NPI:1699868299
Name:DALE, CHARLES LYNN (CO)
Entity type:Individual
Prefix:MR
First Name:CHARLES
Middle Name:LYNN
Last Name:DALE
Suffix:
Gender:M
Credentials:CO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:11140 105TH AVENUE N.
Mailing Address - Street 2:
Mailing Address - City:LARGO
Mailing Address - State:FL
Mailing Address - Zip Code:33778-4101
Mailing Address - Country:US
Mailing Address - Phone:727-397-5583
Mailing Address - Fax:
Practice Address - Street 1:10000 BAY PINES BLVD
Practice Address - Street 2:PROSTHETIC BLDG 23
Practice Address - City:BAY PINES
Practice Address - State:FL
Practice Address - Zip Code:33744-5005
Practice Address - Country:US
Practice Address - Phone:727-398-6661
Practice Address - Fax:727-398-9538
Is Sole Proprietor?:No
Enumeration Date:2006-10-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLN/A225000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225000000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOrthotic Fitter