Provider Demographics
NPI:1871617019
Name:CHARLTON, DAVID J (ATHLETIC TRAINER)
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:J
Last Name:CHARLTON
Suffix:
Gender:M
Credentials:ATHLETIC TRAINER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:909 KERI WAY
Mailing Address - Street 2:
Mailing Address - City:CORVALLIS
Mailing Address - State:MT
Mailing Address - Zip Code:59828-9382
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1020 EASTSIDE HIGHWAY
Practice Address - Street 2:
Practice Address - City:CORVALLIS
Practice Address - State:MT
Practice Address - Zip Code:59828
Practice Address - Country:US
Practice Address - Phone:406-961-4305
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer