Provider Demographics
NPI:1871726174
Name:HERBERT, CHARLES
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:
Last Name:HERBERT
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 1:535 HWY 314 SW
Mailing Address - Street 2:
Mailing Address - City:LOS LUNAS
Mailing Address - State:NM
Mailing Address - Zip Code:87031-9600
Mailing Address - Country:US
Mailing Address - Phone:505-866-0055
Mailing Address - Fax:505-866-0057
Practice Address - Street 1:180 E HIGHWAY 550
Practice Address - Street 2:SUITE E
Practice Address - City:BERNALILLO
Practice Address - State:NM
Practice Address - Zip Code:87004-5967
Practice Address - Country:US
Practice Address - Phone:505-771-2447
Practice Address - Fax:505-771-2360
Is Sole Proprietor?:No
Enumeration Date:2009-09-02
Last Update Date:2010-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM3741225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM1245380039OtherBERNALILLO FACILITY NPI
NM1386651412OtherBILLING NPI
NM000Q0406Medicaid
NM000Q0406Medicaid