Individual
MR. CHARLES HOLLOWAY BOARDMAN IV
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
OTR
Contact information
Practice address
619 SOUTH MARION AVE, NORTH FLORIDA / SOUTH GEORGIA VETERANS HEALTH SYSTEM, LAKE CITY, FL 32025
(386) 755-3016
Mailing address
355 SW SWEETBREEZE DR, LAKE CITY, FL 32024-3698
(386) 755-3016
Taxonomy
Speciality
Code
Description
License number
State
225X00000X
Occupational Therapist
Primary
OT14416FL
FL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
AA499343
NBCOT
—
01
—
OT14416FL
FLORIDA DEPARTMENT OF HEALTH
FL
Enumeration date
09/19/2005
Last updated
02/25/2012
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