Individual
CHARLES WADE WEAVER
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
ATC, AT, LAT
Contact information
Practice address
11399 DAVIS RD, MIDDLEVILLE, MI 49333-8652
(936) 443-6289
Mailing address
11399 DAVIS RD, MIDDLEVILLE, MI 49333-8652
Taxonomy
Speciality
Code
Description
License number
State
2255A2300X
Athletic Trainer
Primary
2000008006
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
2000008006
ATHLETIC TRAINING CERTIFICATION, BOC
—
01
—
2601001771
ATHLETIC TRAINER LICENSE
MI
01
—
AT2652
LICENSED ATHLETIC TRAINER
TX
Enumeration date
12/28/2017
Last updated
12/28/2017
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