Provider Demographics
NPI:1962906396
Name:BOMBACH, CHARLES EDWARD (COTA)
Entity type:Individual
Prefix:MR
First Name:CHARLES
Middle Name:EDWARD
Last Name:BOMBACH
Suffix:
Gender:M
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:709 PASEO SERENO DR
Mailing Address - Street 2:
Mailing Address - City:HORIZON CITY
Mailing Address - State:TX
Mailing Address - Zip Code:79928-8431
Mailing Address - Country:US
Mailing Address - Phone:915-702-6267
Mailing Address - Fax:
Practice Address - Street 1:709 PASEO SERENO DR
Practice Address - Street 2:
Practice Address - City:HORIZON CITY
Practice Address - State:TX
Practice Address - Zip Code:79928-8431
Practice Address - Country:US
Practice Address - Phone:915-702-6267
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-20
Last Update Date:2018-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX214465225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics