Provider Demographics
NPI:1306045729
Name:MUTIA, CHARLES BONGCAWEL (PHYSICAL THERAPY)
Entity Type:Individual
Prefix:MR
First Name:CHARLES
Middle Name:BONGCAWEL
Last Name:MUTIA
Suffix:
Gender:M
Credentials:PHYSICAL THERAPY
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:421 W WINDSOR RD APT 5
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91204-1945
Mailing Address - Country:US
Mailing Address - Phone:818-551-9973
Mailing Address - Fax:
Practice Address - Street 1:421 W WINDSOR RD APT 5
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91204-1945
Practice Address - Country:US
Practice Address - Phone:818-551-9973
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-16
Last Update Date:2007-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAT 6559225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist