Basic Information
| Provider Information | |||||||||
| NPI: | 1578238846 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SANDT | ||||||||
| FirstName: | CHARLES | ||||||||
| MiddleName: | DEWAYNE | ||||||||
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| Credential: | PTA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1669 PALM RIDGE RD | ||||||||
| Address2: | |||||||||
| City: | MELBOURNE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 329354301 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3212236278 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1705 JESS PARRISH CT | ||||||||
| Address2: | |||||||||
| City: | TITUSVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 327962158 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3212695720 | ||||||||
| FaxNumber: | 3213839514 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/10/2021 | ||||||||
| LastUpdateDate: | 08/10/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/10/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225200000X | PTA31242 | FL | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapy Assistant |
No ID Information.