Provider Demographics
NPI:1871310466
Name:HERRON, CHARLES ISSAC
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:ISSAC
Last Name:HERRON
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 1:419 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BENWOOD
Mailing Address - State:WV
Mailing Address - Zip Code:26031-1105
Mailing Address - Country:US
Mailing Address - Phone:304-281-3023
Mailing Address - Fax:
Practice Address - Street 1:419 MAIN ST
Practice Address - Street 2:
Practice Address - City:BENWOOD
Practice Address - State:WV
Practice Address - Zip Code:26031-1105
Practice Address - Country:US
Practice Address - Phone:304-281-3023
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-09-24
Last Update Date:2024-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV125553494Medicaid
WV1821206228Medicaid
WV1356607394Medicaid