Individual
CHARLES MORRIS LAUDER III
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
ATC, ATL
Contact information
Practice address
1441 W BROADWAY, CENTRALIA, IL 62801-5613
(618) 532-0810
(618) 532-0812
Mailing address
26041 W 10TH STREET RD, CENTRALIA, IL 62801-5947
Taxonomy
Speciality
Code
Description
License number
State
2255A2300X
Athletic Trainer
Primary
096.002987
IL
Other
Enumeration date
12/01/2011
Last updated
12/01/2011
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