Provider Demographics
NPI:1932616943
Name:CHARLES, BRANDON
Entity type:Individual
Prefix:
First Name:BRANDON
Middle Name:
Last Name:CHARLES
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 1:4840 LAFON DR
Mailing Address - Street 2:
Mailing Address - City:NEW ORLEANS
Mailing Address - State:LA
Mailing Address - Zip Code:70126-4122
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2714 CANAL ST
Practice Address - Street 2:
Practice Address - City:NEW ORLEANS
Practice Address - State:LA
Practice Address - Zip Code:70119-5548
Practice Address - Country:US
Practice Address - Phone:504-301-2888
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-12-29
Last Update Date:2018-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1356720866Medicaid
LA1356720866OtherFUTURE WINNERS