1386858959 NPI number — CHARLES T SPINA PT,JSCC,CEAS

Table of content: CHARLES T SPINA PT,JSCC,CEAS (NPI 1386858959)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1386858959 NPI number — CHARLES T SPINA PT,JSCC,CEAS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SPINA
Provider First Name:
CHARLES
Provider Middle Name:
T
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PT,JSCC,CEAS
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
SPINA
Provider Other First Name:
CHUCK
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
PT,JSCC,CEAS
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1386858959
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/02/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6596 N RAISINA AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FRESNO
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
93710-3945
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
916-214-3941
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7005 N MAPLE AVE
Provider Second Line Business Practice Location Address:
SUITE 104
Provider Business Practice Location Address City Name:
FRESNO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
93720-8009
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
559-325-3503
Provider Business Practice Location Address Fax Number:
559-325-3504
Provider Enumeration Date:
05/10/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , with the licence number:  PT15431 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 2251E1200X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: CK761U . This is a "MEDICARE PTAN" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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