Individual
JAKE CHARLIE
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Contact information
Practice address
167 N. MAIN STREET, TUBA CITY, AZ 86045-0600
(928) 283-2501
Mailing address
PO BOX 600, TUBA CITY, AZ 86045-0600
(928) 283-2501
Taxonomy
Speciality
Code
Description
License number
State
172A00000X
Driver
Primary
CNA999953632
AZ
Other
Enumeration date
10/27/2010
Last updated
10/27/2010
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