Provider Demographics
NPI:1194001875
Name:KOO, CHARLES C (MT PRACTITIONER)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:C
Last Name:KOO
Suffix:
Gender:M
Credentials:MT PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:430 SHERMAN AVE STE 205
Mailing Address - Street 2:
Mailing Address - City:PALO ALTO
Mailing Address - State:CA
Mailing Address - Zip Code:94306-1853
Mailing Address - Country:US
Mailing Address - Phone:650-701-7246
Mailing Address - Fax:
Practice Address - Street 1:430 SHERMAN AVE STE 205
Practice Address - Street 2:
Practice Address - City:PALO ALTO
Practice Address - State:CA
Practice Address - Zip Code:94306-1853
Practice Address - Country:US
Practice Address - Phone:650-701-7246
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-10-26
Last Update Date:2011-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA24005225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist