Provider Demographics
NPI:1205182615
Name:CHARLES SHANE DANIELS MD
Entity Type:Organization
Organization Name:CHARLES SHANE DANIELS MD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:SHANE
Authorized Official - Last Name:DANIELS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:714-456-3472
Mailing Address - Street 1:34145 PACIFIC COAST HWY
Mailing Address - Street 2:#603
Mailing Address - City:DANA POINT
Mailing Address - State:CA
Mailing Address - Zip Code:92629-2808
Mailing Address - Country:US
Mailing Address - Phone:714-456-3472
Mailing Address - Fax:
Practice Address - Street 1:25652 OLD TRABUCO RD
Practice Address - Street 2:
Practice Address - City:LAKE FOREST
Practice Address - State:CA
Practice Address - Zip Code:92630-2776
Practice Address - Country:US
Practice Address - Phone:714-456-3472
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-08-03
Last Update Date:2012-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA94985208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Single Specialty