Provider Demographics
NPI:1679538789
Name:HAAGA, CHARLES KEITH (ATC)
Entity type:Individual
Prefix:MR
First Name:CHARLES
Middle Name:KEITH
Last Name:HAAGA
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1104 CHARLIE DR
Mailing Address - Street 2:
Mailing Address - City:SLIDELL
Mailing Address - State:LA
Mailing Address - Zip Code:70461-5346
Mailing Address - Country:US
Mailing Address - Phone:985-781-1635
Mailing Address - Fax:
Practice Address - Street 1:1104 CHARLIE DR
Practice Address - Street 2:
Practice Address - City:SLIDELL
Practice Address - State:LA
Practice Address - Zip Code:70461-5346
Practice Address - Country:US
Practice Address - Phone:985-781-1635
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAJ001242255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer