Basic Information
| Provider Information | |||||||||
| NPI: | 1700956414 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WELLY | ||||||||
| FirstName: | CHARLES | ||||||||
| MiddleName: | W. | ||||||||
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| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 8310 | ||||||||
| Address2: | |||||||||
| City: | ROANOKE | ||||||||
| State: | VA | ||||||||
| PostalCode: | 240140310 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5403453556 | ||||||||
| FaxNumber: | 5403422193 | ||||||||
| Practice Location | |||||||||
| Address1: | 5 W BACK ST STE 101 | ||||||||
| Address2: | |||||||||
| City: | FINCASTLE | ||||||||
| State: | VA | ||||||||
| PostalCode: | 240904368 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5407693964 | ||||||||
| FaxNumber: | 5404733458 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/09/2006 | ||||||||
| LastUpdateDate: | 08/17/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 08/17/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 2248 | AZ | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 0102204907 | VA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.