Provider Demographics
NPI:1649864893
Name:SHAFER, CHARLES CURTIS (MT)
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:CURTIS
Last Name:SHAFER
Suffix:
Gender:M
Credentials:MT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9419 N MAY AVE
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73120-2708
Mailing Address - Country:US
Mailing Address - Phone:405-388-2563
Mailing Address - Fax:
Practice Address - Street 1:9419 N MAY AVE
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73120-2708
Practice Address - Country:US
Practice Address - Phone:405-388-2563
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-02-26
Last Update Date:2021-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK177039225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist