Basic Information
| Provider Information | |||||||||
| NPI: | 1649433038 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FUNK | ||||||||
| FirstName: | CHARLES | ||||||||
| MiddleName: | M | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | PT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11219 CORALBEAN DR | ||||||||
| Address2: | |||||||||
| City: | LAKEWOOD RANCH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 342022894 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9419189575 | ||||||||
| FaxNumber: | 9413469646 | ||||||||
| Practice Location | |||||||||
| Address1: | 9122 TOWN CENTER PKWY STE 102 | ||||||||
| Address2: | |||||||||
| City: | LAKEWOOD RANCH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 342025050 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9413733910 | ||||||||
| FaxNumber: | 9413469646 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/07/2008 | ||||||||
| LastUpdateDate: | 07/07/2008 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | PT6558 | FL | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.